Grounding the Frequent Fliers
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This article appears in the April 2013 issue of HealthLeaders magazine.
They come into the emergency department as if it's their second home; indeed, they often are on a first-name basis with the medical personn el who are there to greet and treat them. On this particular Sunday night in a suburban Washington, D.C., hospital, a patient is in the ED, smiling but with a bloodied face. A nurse whispers in the hallway: "Mary's alcohol level is high again." Just as the bartenders at the local taverns do, the ED nurses know Mary. She is a regular. Scenes like this one are being played out regularly across America, like well-worn reruns.
Theodore I. Benzer, MD, PhD, FACEP, is chairman of ED quality and safety and director of clinical operations for the department of emergency medicine at Boston's 907-licensed-bed Massachusetts General Hospital. He sees and treats many of the patients who return to the ED time and again—at least five to 12 times a year or more. "They are so near and dear to us," Benzer says. "This is our group of patients we feel we know."
These are the so-called frequent fliers, a broad term that covers patients with varying needs. Some of these rebounders are challenged by alcohol or drug abuse issues or they need mental healthcare. Others choose the ED because they have no health insurance or primary care physician. Some are driven by fear and suffering associated with chronic pain but are reluctant to make an appointment to see their primary doctor—or their doctor is reluctant to see them yet again.
"We have very much longed for the opportunity to see new ways of taking care of these patients … to meet their needs, but in less and less costly ways," says Ted Townsend, president and CEO of the 250–300-staffed-bed St. Luke's Hospital in Cedar Rapids, Iowa, which has been working to reduce frequent fliers' usage of the ED. "We need to intervene with these patients in a different way."
The urgency of grounding frequent fliers has prompted hospitals, healthcare systems, and academics to initiate strategies to curtail what many believe will become more of an acute problem. Insurers are working with hospitals to implement programs for mentally ill patients and others with chronic conditions in an attempt to divert the patients into hospital-sponsored coordinated care plans that connect with government and community organization–provided services. Case managers closely monitor frequent fliers by following up after ED visits to prevent recurring hospital stays. Hospitals are installing electronic medical record programs that may flag frequent fliers for primary care physicians and community organizations.
Hospitals are assigning nurses and social workers to pore over records to identify patients who come to the hospital too often and actually are alerting the patients themselves that they may need primary or psychological medical care, not another trip to the ED.
"Each month, we review the frequent fliers, and some who are even very frequent fliers, the patients who come five or six times a month," says Benzer. Whether the patients use the ED five times a year or five times a month, he says, "Over the years, we've found what other hospitals are finding: A lot of these patients have drug, alcohol, or substance concerns, and there are some who are homeless."
Also, there are patients who repeatedly use the ED who have "very severe and complex medical problems," Benzer says. "It's very complicated. The sad part in all of this is that, in medicine, in terms of treatment, it's not easy. It's not like giving penicillin for strep throat; there's no 100% cure." Patients "may be drunk, but drunk people have heart attacks and skull fractures. When they get drunk they can't tell you how they are feeling."
Because of the complexities involved with ED frequent fliers, MGH has been coordinating programs with city and state social service organizations with a simple goal: "We can get them into a program rather than the ED," Benzer says.
For hospitals, frequent fliers are a strain not only because of the high cost of running the ED, but because repeat users add to overcrowding and wait times that impact patients with emergent care needs. Better treatment of this population has never been more urgent for hospitals, what with reimbursement changes away from fee-for-service and upcoming 30-day readmission penalties from the federal government. As more elements of the Patient Protection and Affordable Care Act get implemented, emergency medicine physicians expect the use of EDs to increase when as many as 40 million previously uninsured people flow into the system.
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