A study finds reductions in emergency department usage can be achieved through patient education, interventions in patient financial incentives, and the adoption of population health strategies such as patient-centered medical homes.
Outside interventions can be successful in reducing emergency department usage in U.S. hospitals, a new study finds.
In the study "Non–Emergency Department Interventions to Reduce ED Utilization: A Systematic Review [PDF]," published in the October issue of Academic Emergency Medicine, researchers analyzed literature from studies conducted on the effectiveness of interventions introduced outside of the hospital that were aimed at reducing ED utilization.
"With the roll out of the Affordable Care Act and especially with new payment models that are being developed, there is a much greater focus on reducing high-cost utilizations… such as ED use and inpatient hospitalizations and on improving the efficiency of healthcare in general," says Jesse Pines, MD, study co-author.
Pines is director of the Office of Clinical Practice Innovation and a professor of emergency medicine and health policy at the George Washington University School of Medicine and Health Sciences in Washington, D.C. his team's research identifies five ways in which hospitals have been successful in reducing ED usage through outside interventions:
1. Provide Patient Education
Providing patients with information on common symptoms and complaints can prevent unnecessary ED visits, Pines says. "Patient education is a good example of where in general if we can better educate people about the most ideal setting for their complaints and when to seek care, we can very effectively reduce not only ED use but all healthcare use."
Pines warns that patient education can sometimes be a "double-edged sword because there is so much information out there on WebMD.com and other websites… It's very important how information is delivered and that patients are allowed to understand the context of their specific complaint."
2. Add Non-ED Capacity
Health systems can reduce ED visits by offering extended primary care hours and opening urgent care centers. "The addition of capacity outside of the ED can have a small reduction in the use of emergency departments, especially for low acuity visits," Pines says, noting that the added access may encourage visits that might otherwise never have occurred.
"There is the issue of 'if you build it, they will come,'" he says. "As a cost-saving measure, it can potentially backfire" because of supply-induced demand.
3. Explore Managed Care Models / Population Health Strategies
Pine says new care models, such as accountable care organizations and patient-centered medical homes, will likely result in a decrease in ED visits. "We are going to be seeing more of these managed care interventions where organizations are paid differently with a goal of reducing utilization. I think those programs can be effective, but they need to be monitored carefully to make sure they are safe for patients," he says.
4.Offer Pre-Hospital Diversions
While the study only includes two papers on pre-hospital diversions, Pine says there is one strategy in particular that may be promising: allowing paramedical professionals to determine if a patient who has called an ambulance needs to go to the ED or to another site of care. "Paramedics are not used to their greatest degree," he says.
One way to improve the value of medical care in general is to allow providers to operate at the top of their license," Pines says. "However, it's important to note that if the paramedic determines it is not necessary for the patient to be seen in the ED, there has to be an alternative for that patient who has called the ambulance because they want medical care."
Pines acknowledges that hospitals and paramedics may be resistant to this intervention due to possible legal concerns.
5.Break Down Financial Barriers
The study indicates that higher insurance co-pays reduce ED usage, Pines says, adding that this tactic could create care access issues for many patients. "If you start creating barriers to care, which is where a lot of financial incentives come in with higher co-pays for people and introducing capitation and new payment models like ACOs—where providers will not have an incentive to do more—it's important to look at the other side," he says.
"Does it create patient safety problems? Are certain patients not getting needed care because there is a barrier in place? The problem when you start raising co-pays is that Bill Gates will still get medical care regardless of cost, but people who are much more vulnerable may not have access."
Pines says that while these interventions have been shown to be effective, hospitals and health systems cannot take a one-size-fits-all approach to decreasing ED usage.
"It's important to say that what works in one setting may not work in another. The notion that healthcare interventions can be picked out of one setting and put in another is not necessarily true. It depends on the individual needs and resources of the patient populations, which can vary tremendously between communities," Pines says.
He is also quick to point out that simply decreasing ED usage should not be the total goal. Hospitals and health systems must also look for ways to increase the value of the care they deliver while always keeping a sharp focus on quality and outcomes, he says.
"Driving down ED care is good for insurance companies, but it may not be good for hospitals and it may not be good for patients, especially if patients don't get the care they need and end up getting worse," Pines says. "We need to create programs that reduce ED use and use across all care settings that doesn't add value. And we need to understand where increased utilization really enhances value to the patient."