Poor Care Coordination Affects Patients with Ambulatory Care-Sensitive Conditions
By Melinda Young
A veteran population at risk of poor outcomes after being treated in an ED needed follow-up care and outreach to improve care coordination, according to recent research.1
“In general, care coordination is important for preventing poor outcomes across care transitions,” says Kristina Cordasco, MD, MPH, MSHS, lead study author and a core investigator with the VA Center for the Study of Health Care Innovation, Implementation, and Policy. “Previous studies have shown that when there is poor coordination across care transitions, patients are vulnerable to poor outcomes. What we looked at was patients who were sent home or to a nursing home directly from the emergency department and were not hospitalized.”
Patients with unmet needs after an ED visit are more likely to report poor outcomes, including returning to the hospital. “We looked at the needs of patients with chronic ambulatory care-sensitive conditions,” says Cordasco, an internal medicine physician at the VA Greater Los Angeles Healthcare System and a clinical professor of medicine at the University of California, Los Angeles. “The five conditions that are considered are asthma, chronic obstructive pulmonary disease [COPD], heart failure, diabetes, and hypertension.”
Patients’ quality of care is associated with whether they visited the ED or were hospitalized for those chronic conditions. “The better ambulatory/outpatient care they have, the less likely they’ll have an emergency department visit or hospitalization,” Cordasco explains.
Cordasco and colleagues studied patients’ follow-up needs after ED visits. “We know patients with an exacerbation of a chronic illness by the inherent nature of that condition will have persistent needs after emergency department visits,” she says.
Even when the patient is stabilized in the ED and treatment is initiated, flare-ups can occur. Patients still need chronic care. “The initial treatment, started in the ED, is not sufficient for their treatment,” Cordasco says.
For example, an ED patient with heart failure may be prescribed medication to eliminate fluid. But the dosage may need adjustment after the patient is discharged.
“Follow-up care may be needed to see how the patient responded to that medication and to make any adjustments to the [prescribed] dose,” Cordasco explains.
Medication changes are a common need for patients discharged from the ED. “We found that more than half of the patients discharged home from our VA emergency department had been directed to having a change in their medication — either starting a new one or changing the dose — or even stopping a medication,” Cordasco says. “This suggests a follow-up is important.”
Most patients’ post-ED care needs are directed toward primary care. Health systems must address which type of care team can address those needs. For instance, many patients could be monitored remotely through phone or video calls. Also, many could be assessed for symptom issues and disease management by members of a care team rather than a primary care provider, including nurses and pharmacists.
From a hospital’s perspective, it is important to create tools and processes for educating ED patients and their caregivers about medications and care management. “You could use a pharmacist to make sure counseling is done about their medications, and they can use best practice methods, such as the teach-back method,” Cordasco notes. “They can have the patient teach back what they told them about their medication to ensure the education was effective.”
Hospitals also can focus on communication with patients and their caregivers at discharge. “Talk about any medication changes and educate them about the importance of follow-up care,” Cordasco says. “Patients are more likely to get follow-up care if the appointment is made for them while they’re still in the emergency department.”
Many hospitals, including VA hospitals, use electronic health records (EHRs) as part of their communication processes. But are these EHRs, which can send emails and messages to patients and share information with other providers, sufficient for meeting patients’ follow-up communication needs?
“Have they gotten the follow-up care they need?” Cordasco asks. “The next step is to develop and implement any solution for patients who are not getting their needs met.”
One potential solution is an ED-PACT tool, which stands for Emergency Department and Patient-Aligned Care Team. It allows ED providers to send communication to primary care team nurses. Cordasco and colleagues developed, implemented, and evaluated the tool, which uses the VA’s EHR, to send messages from ED providers to primary PACT registered nurses for veterans discharged from the ED.2
“That’s the system we have put in place in our VA hospital in order to communicate with VA care managers on the primary care side,” Cordasco says. “The primary care provider does that follow-up based on those needs.”
ED providers send short messages to the primary care team, listing any specific or urgent follow-up needs. ED providers can track messages and verify receipt by the primary care team.
“The nurse then receives and triages the message, working with the primary care provider and primary care pharmacist, social worker, and administrative care clerk to reach out to the veteran,” Cordasco says. “That is a solution that works for us because we’re an integrated healthcare system, and most veterans have a primary care team appointed to them.”
- Cordasco KM, Yuan AH, Aoki K, Ganz DA. Patients’ needs following emergency care for ambulatory care-sensitive conditions. Am J Manag Care 2022;28:232-236.
- Cordasco KM, Saifu HN, Song H-S, et al. The ED-PACT tool initiative: Communicating veterans’ care needs after emergency department visits. J Healthcare Qual 2019;42:157-165.
A veteran population at risk of poor outcomes after being treated in an ED needed follow-up care and outreach to improve care coordination, according to recent research. Patients with unmet needs after an ED visit are more likely to report poor outcomes, including returning to the hospital.
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