Article Images
Most emergency departments have a group of frequent users who come to the hospital several times a year and rack up thousands of dollars in services. Hospitals must treat these patients, even when their problems are only in part medical, even when they leave behind unpaid bills.

It's tempting to assume that homelessness or behavioral health issues define these patients. In fact, there is little commonality among them. "People lump all frequent users under one label, but there seem to be many distinct groups in this category," Elaine Rabin, M.D., co-author of a 2010 Annals of Emergency Medicine study on frequent users, said in a statement. Patients may present with anything from poorly controlled asthma to housing insecurity, which means there is no one-size-fits-all solution.

Provider organizations can't afford to sustain this kind of care: the National Association for Community Health Centers estimated in 2006 that more than $18 billion annually is spent on ED visits that are nonurgent or could be treated in a physician office or health clinic.

For trustees, getting a handle on inappropriate ED use can look like a financial issue, but it's also connected to other top priorities: taking responsibility for the health of their communities and ensuring that every patient gets quality care. So hospitals are targeting frequent users and trying to understand who they are and how to guide them to seek treatment in the most appropriate setting.

Beyond Medical Care

Providers who decide to bring under control the care and costs of high-frequency patients use a common approach: after identifying the patients, they deploy intensive case management to tackle a variety of circumstances that lead to high ED use. Behavioral health needs, multiple chronic conditions and medically fragile elderly make up most of the ED visitors, but other, nonclinical problems like homelessness, lack of transportation or an absence of family support contribute to frequent visits.

The Bridge program at Kaweah Delta Hospital in Visalia, Calif., for instance, has four community health outreach workers who work closely with frequent ED patients, many with unresolved social issues or who need help managing chronic illnesses and understanding their medications. Outreach workers meet with patients before discharge in the hospital, at their homes or in the case of homeless patients, a public place, and explain the Bridge's services and the patient's discharge plan. Depending on the patient, the outreach worker will develop a care plan that addresses behavioral health issues, assist in obtaining medications, schedule appointments or coordinate housing. Outreach workers also aim to empower patients by coaching them on how to advocate for themselves with medical and social service providers.

In one situation, case workers helped a man who had been homeless for 10 years. They ordered his birth certificate from Texas, enrolled him in Medi-Cal and Social Security disability, and found him a place to stay in a residential care facility. The Bridge has been so successful in getting patients the help they need, hospital inpatient unit managers are clamoring for help from the case workers who currently focus mostly on the ED. The program resulted in a 44 percent reduction in ED visits for patients followed for one year; the cost savings were calculated at $113,049, according to John Tyndal, Kaweah Delta's director of community outreach.

At Santa Barbara (Calif.) Cottage Hospital, an intensive case management system resolved a number of ED issues, says system CEO Ronald Werft. "It saved just under a million dollars a year, just on adult use of the ED," he says. The program was developed because physicians, nurses, hospital leaders and patients noticed the large number of unnecessary visits by a small group of people. The initial assumption that the group was mainly indigent people with addictive behaviors was wrong; two-thirds were homeless, but the rest had financial resources. They found that a key driver for many of the adult patients was loneliness and the need for an ongoing relationship with a caregiver. They also identified a separate population of mothers with children, who were using the ED because they didn't know there were better options for primary care.

The program maintains a list of people who are overusing the ED and focuses on the top 20 for a given year, moving to the next 20 the following year. For each patient, team members create a care plan focused on individual interventions that do not require hospitalization and include a brief medical history, social and psycho-social issues, history and assessment.

When a frequent user comes to the ED, the plan is reviewed and updated. After the patient is cleared by the ED physician, a case manager or medical social worker gets involved, helping to remove barriers to accessing care, such as looking up bus schedules or making appointments. Throughout the process, case management team members aim to build a sense of trust with the patient. They also attempt to create a medical home for each individual, connecting with local clinics to find a regular, primary care provider. "The volume of ED visits is way, way down," says Todd Cook, the system's care management director. The program has worked so well that it's being expanded to focus on patients with unmet mental health needs.

Another positive about the program, Werft says, is that it was developed from the ground up by staff members who saw a problem and designed a solution, taking advantage of the system's culture of shared governance. "We strongly believe that making sure we are providing employees with the tools they need to do their jobs well will result in greater employee satisfaction and also very high levels of patient satisfaction," he says.

The relationships forged through the case management program led to a weekly Monday huddle of representatives from the hospital, social service agencies and community organizations. "This process certainly enhances and strengthens our relationships with the county, with clinics, with CenCal [the local Medicaid agency] and with the physicians who are actively engaged in taking care of patients," Werft says.

Reducing readmissions drives a high-touch program at Mount Sinai Hospital in Chicago. Earlier this year, Willie Barnes, 65, was admitted to Mount Sinai after showing up in the ED with shortness of breath. Barnes, who had had triple bypass surgery 10 years ago, was ultimately enrolled in Sinai's congestive heart failure program, which is designed to prevent readmissions.

Every week or so, Barnes gets a call from a Mount Sinai disease manager, who checks in with him on both his diet and medication adherence. In that time, the disease managers helped Barnes fill a prescription he was having difficulty getting from a local drugstore, and helped him shed a two-liter-a-day soda habit.

Two months later, Barnes says he's lost 30 pounds and is no longer suffering from shortness of breath.

Fellow program member Valerie Shavers, who was diagnosed with congestive heart failure last year after an episode in which she lost consciousness while driving her car, has stopped smoking, drinking carbonated soda and eating microwaved food.

Shavers, who is also a cancer survivor, says the disease manager and patient navigators with whom she talks each week at Mount Sinai differ significantly from health care professionals and counselors she's encountered during previous clinical experiences. "They were more like a friend calling," she says. "[We talk about] the weather, or if I'm going out of town."

Since they joined the program, neither Barnes nor Shavers has been readmitted to Mount Sinai, says Roelean Duncan, R.N., a disease manager who works with both patients.

The Community Angle

Because they focus on day-to-day clinical issues, frequent patient management programs are likely to operate below the radar of the typical board member, whose job is to keep an eye on bigger strategic issues. Nevertheless, trustees who sit on the quality committee or also serve on boards of other community organizations may become aware of ED usage issues and how the problems of frequent patients illuminate other unmet needs in the community, such as access to behavioral health care or affordable housing.

At Cottage, the board's quality committee has been kept apprised of developments with the ED case management program. In fact, it was a committee discussion that led to its expansion into the population with unmet mental health needs. "We had a great conversation in the quality committee around how rules around psychiatric holds were compromising our ability to provide the highest level of emergency care to those who need emergency services," Werft says. "We started brainstorming about engaging county mental health [personnel] or going beyond county boundaries for assistance."

It's part of the board's role to address these community health issues, says Joan Lindenstein, a hospital community health consultant in Gibbon, Neb. She sees hospital boards tracking community needs and ensuring that the hospital is tackling them using best practices.

It's also up to the board, Lindenstein says, to be sure that new programs are measured and tracked to demonstrate their value. "That's a key responsibility of the board … to ask how we are measuring to see if we've really impacted what's happening in our community."

Hospitals increasingly are looking to prevention to get ahead of the problem, while researchers try to figure out reliable ways to predict which patients are likely to end up as frequent users. That kind of preventive strategy requires a well-developed community health approach, requiring hospital leaders to at least be aware of what's going on in the community, even if they are not issues the hospital can resolve.

For example, "the hospital doesn't control the factors that cause asthma," says Michael Bilton, executive director of the Association for Community Health Improvement, an American Hospital Association personal membership group. But it's in the hospital's interest, particularly when taking financial responsibility for the health of a population, to ensure that something is being done to reduce the number of new and uncontrolled cases of asthma that might show up in the ED. "It's a matter of dealing with health issues in the community before they reach the hospital," he says.

Jan Greene is a freelance writer in Alameda, Calif. Haydn Bush, senior online editor of Hospitals & Health Networks magazine, contributed to this article.

Online Exclusive

Providers are putting health IT and mobile devices to work in reducing readmissions. For more on this topic, see the Web-only feature "Technology Is the Best Medicine".

Sidebar - California's Promising Strategies

Sidebar - 'Hot Spotting' in Camden, N.J.