Visiting Scholar’s QI Project Aims to Improve Care for Frequent ED Users
In 2012, approximately 134 million total ED visits occurred, or nearly 430 ED visits for every 1,000 individuals in the U.S. population.¹ It is estimated that frequent ED users comprise 4.5% to 8% of all ED patients and account for 21% to 28% of all visits.²
Can community health workers (CHWs) and enhanced provider engagement improve the quality and cost of care for patients who frequently visit the emergency department (ED)?
The preliminary answer is “yes,” says Michelle Lin, MD, MPH, a Health Policy Research Fellow at Brigham and Women’s Hospital, who is also a scholar in the first class of the ABMS Visiting Scholars Program. Dr. Lin was chosen with four other physicians for the one-year, part-time program intended to help scholars develop their research skills and scholarship by engaging in a research project related to Board Certification and Maintenance of Certification (MOC)/Continuous Certification; contribute to the scholarship about innovations/best practices of continuous professional development, assessment, quality improvement (QI), and health policy; and familiarize themselves with health policy and the external environment in which continuous certification occurs. Dr. Lin’s QI project builds on existing research at the hospital that was awarded funding from the Brigham and Women’s Provider Organization Care Redesign Incubator and Startup Program to implement it.
Midway through the QI project, Dr. Lin reflected on the early findings. “The purpose of this project is to engage ED providers in the longitudinal care of patients who frequently visit the ED. This is something emergency physicians typically do not think of as part of their job,” she continued. “But seeing the same patients over and over again for the same problem can be frustrating for emergency physicians, and it’s empowering to realize that they can improve the quality of care for these patients.”
The biggest misconception about frequent ED users is that they lack a primary care provider (PCP) and are uninsured, Dr. Lin said. In Massachusetts, however, most patients are insured thanks to statewide health care reform implemented in 2006. Approximately half of the frequent ED users enrolled in the intervention had a PCP within the health system, but only half of them saw their doctor in the six months prior to enrollment. So, in theory, these patients had access to health care providers, she said. But they could have problems scheduling regular appointments, for example, either due to a disability or timing. They may lack transportation to get to appointments or money to pay for medications. Although some of these patients have substance abuse issues, they also have multiple chronic diseases that require ongoing care. “This group is more challenging, in some ways, because you can’t just get them to a primary care doctor and fix the situation,” she said.
To date, the project team has identified the hospital’s top most frequent ED users and developed acute care plans for 20 of them. An acute care plan summarizes pertinent information about a patient's medical and social history, which is often complex, and serves as guidance for acute care/emergency providers who are usually unfamiliar with the patient's history. It offers recommendations regarding approaches to acute exacerbations of chronic medical problems; contact information for the patient’s PCP, key specialists, caregivers, and a social worker; and detailed guidance for facilitating close follow-up. Leading the development of the care plans, Dr. Lin worked with Jeremiah Schuur, MD, MHS, her mentor and project co-leader, as well as other ED physicians and specialists, residents, physician assistants, and nurses. It is important to have the patients’ PCP on board to ensure that a provider who knows the patient well is driving the plan, she said. Because emergency providers are not as familiar with patients’ ongoing medical problems, acute care plans are one way to help standardize the treatment of acute exacerbations of chronic illness. “What you don’t want to happen is the patient presenting to the ED five times and given five different treatments,” Dr. Lin said.
Next, the team hired a CHW to help these patients navigate their way through the health care system. The CHW often visits patients in their homes to assess their living conditions and how it may impact their ability to make and keep appointments. As an example, a gas leak that the frequent ED user can’t fix in his or her apartment could be causing frequent headaches and stress. “As physicians, we are not trained, nor do we have the resources, to deal with such issues that clearly affect the health of these patients,” Dr. Lin noted. But a CHW is trained in navigating social services to facilitate access to health care.
The project team developed an electronic alert that is triggered when a frequent user presents to the ED. At this point, the CHW is paged. Eventually, these frequent user alerts will be visible to all emergency providers. The health system is in the process of switching to a unified electronic health record, which will have this alert built into it, she explained.
Dr. Lin’s team currently has funding to continue the CHW pilot intervention through June 2015. By that time, the team will have finished collecting more than six months’ worth of data on the frequent ED users, allowing for the full program effect to be analyzed. In the meantime, they have begun to analyze preliminary results with the goal of securing renewed funding before the pilot ends.
The preliminary data suggests that ED frequent users who worked with the CHW and had an acute care plan had fewer ED visits and hospitalizations compared with patients who were not enrolled in the intervention, Dr. Lin stated. Although the medical literature on cost savings for the use of a CHW and coordination care plans is mixed, most studies are cost-neutral or show a positive cost benefit. This type of effort improves patient care long-term, and while money is spent on the front end, a cost savings is realized on the back end, she explained.
Next, Dr. Lin will be developing a module to meet the American Board of Emergency Medicine’s MOC requirements for a Part IV activity with the monies awarded from the Visiting Scholars Program. The module will consist of a chart review and summary of the current evidence regarding frequent ED users and existing interventions. Emergency physicians will be able to provide their input regarding improvement interventions, including feedback on this one. “This tool will enable ED doctors to review the most frequent ED users at their institutions,” she said.
Given that emergency physicians are sometimes the providers who frequent ED users see the most, ED-based care coordination can play a critical role in better meeting these patients’ complex needs, Dr. Lin noted. While care management programs have proliferated and are well studied in primary care settings, clinic-based programs are not reaching many frequent ED users, as was the case at Brigham and Women’s Hospital. “Through this QI project, we have come to realize that an ED-based community health worker and care coordination program meets a unique need for this patient population currently not being met,” she noted. Dr. Lin plans to present the QI project at the September 2015 ABMS conference and publish a study about it in a peer-reviewed journal.
Bridging the gap between the care these patients receive from emergency physicians and their PCPs will be increasingly important as health systems shift toward more accountable care, Dr. Lin added. This QI project shows it can be done.
1. 2012 National Statistics on All ED Visits. U.S. Department of Health & Human Services. Agency for Healthcare Research and Quality. http://hcupnet.ahrq.gov/HCUPnet.jsp?Id=AFE2D523EAA4F8A5&Form=DispTab&JS=Y&Action=Accept (Accessed June 2, 2015).
2. LaCalle E, Rabin E. Frequent users of emergency departments: the myths, the data, and the policy implications. Ann Emerg Med 2010;56(1):42-8.