Healthcare News & Insights

Pivotal care that drastically cuts emergency room overuse

Reducing costs is at the top of all health executives’ minds — more so now than ever before since hospitals are facing a possible 1% Medicare pay cut  for high readmission rates starting in October. So where do you begin?

Emergency department (ED) overuse is one area.

While there is no set standard for what constitutes “overuse,” an accepted measure used by researchers is four or more annual visits. And according to a July 2006 Annals of Emergency Medicine study, 8% of patients who use the ED four or more times a year account for 28% of adult ED visits.

If hospitals could cut that number in half, think of the savings.

But what can facilities do when these people are abusers of the system, right? You can’t can turn them away.

First off, the belief that the majority of these people are abusers of the healthcare system isn’t backed up by evidence, Dr. Ellen Weber, co-author of the Annals study, noted in They’re people who are chronically ill, often with mental illnesses that make it more difficult to manage their physical illnesses.

Secondly, these people aren’t just visiting EDs instead of utilizing the outpatient care system, added Dr. Weber, professor of clinical emergency medicine at the University of California, San Francisco School of Medicine (UCSF). They are using the ED in combination with everything else the healthcare system has to offer. And it’s not like going to an ED is fun or saves time.

The problem is, these people have real issues that aren’t being treated or followed up on. When these underlying problems are addressed, facilities can cut ED overuse drastically.

Case No. 1: Spectrum Health Systems

At Spectrum Health Systems in Grand Rapids, MI, 950 patients were identified as using their hospital ED 10 times or more over the course of a year. In that time, those patients garnered more than 20,000 ED visits for a total cost of at least $40 million.

But thanks to Spectrum’s new Center for Integrative Medicine  — a $1 million multi-specialty clinic modeled on a pilot program that cut ED use by nearly 90% — approximately one-third of the 100 high-volume ED patients who have been seen are completely stabilized and being treated by primary care physicians.

The majority of these patients have chronic pain and mental health problems. The clinic’s goal is to find the source of the pain and address the patient’s medical, psychological and social needs.

The first visit can last as long as four to five hours. The patient sees a case manager and a medical social worker first,  then they see Dr. Corey Walker, the medical director, for a complete medical work-up.

While some patients don’t have a discernible source of pain, these patients aren’t dismissed. Dr. Walker works to wean them off opiates by using buprenorphine and other similar medications. They also receive counseling on using cognitive-behavioral therapy and other techniques to cope with their aches and pains, and the stressors of daily life.

Case No. 2: Bellevue Hospital Center

At Bellevue Hospital Center in New York City, Dr. Maria Raven helped launch a similar pilot program, which cut ED visits by 10% and hospitalization by nearly 40%.

It treated 19 patients who combined had 106 ED visits and 64 hospital admissions in a year. Eighteen of those patients had substance-abuse problems and 17 were homeless.

The facility hired a care manager to coordinate care for inside and outside the hospital, explained Dr. Raven, who is now assistant professor of clinical emergency medicine at USCF.

Through in-depth interviews the patient’s housing, transportation and medical needs were identified. Then instead of  discharging patients to go back to their life on the streets, the staff found permanent housing for them and often gave them prepaid cell phones to help coordinate their ongoing care.

In addition, weekly conference calls with primary care doctors; visiting nurse services; methadone, substance abuse and other programs were conducted to help ensure continuity of care.

Does your facility employ a program such as these to reduce overuse-ED patients? If so, share what kind of results you have experienced in the box below.



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