"Such patients are often the focus of conversation among the hospital's quality committee personnel and staff, says Williamson. "We always ask: 'Are we missing something? Did we fail the patient the first time around?' There were a whole bunch of psychological, social, and economic issues involved.
"These patients weren't connecting with their care, and coordination was lacking," Williamson adds. "And sometimes the patient may have a goal, but doesn't have the executive function to follow through on those goals, [such as] making the next appointment or getting to the next step in care. We are always the safety net."
MGH leadership committees explore data that identifies the frequent ED users. Once it's established who they are, the hospital reaches out to these patients and makes appointments with primary care physicians or other specialists such as psychiatrists, if necessary, Benzer says. "In that way, a direct relationship is established between the hospital and the patient."
A care manager presents individual plans to the patient's primary care provider or finds a primary care physician if the patient doesn't have one. The care manager also informs the patient's provider about the frequency of the patient's ED visits and the treatment the patient received each time. At MGH, letters are sent to primary care physicians to make them aware that their patients have used the ED frequently and should be involved in a program to reduce the trend. At St. Luke's, similar letters are sent to patients, many of whom agree to pursue specific care plans with their physician once they are helped to negotiate the healthcare system.
Case management programs can be cost-effective. Reduction in hospital costs exceeded the cost of the case management team, according to a July 2011 report from the Annals of Emergency Medicine. That research shows a median cost reduction per patient of $2,406. For all hospital services, potential cost savings were estimated at $10 million per year for 157 patients enrolled in a two-year program.
"Our systematic review suggests that interventions targeting frequent users of hospital EDs may be effective at reducing ED use," the report states. "Case management, the most described intervention, could reduce ED costs and may also improve social and some clinical outcomes."
Following the care plan
At St. Luke's, 12 is the magic number for dealing with frequent fliers. After a dozen visits, patients receive notification in the mail of their inclusion in the consistent care program. The letter includes an introduction to the program, a copy of their care plan, and a release of information that they are asked to sign so their medical information can be shared with other care providers.
After the patient is enrolled in the program, the case manager reviews the patient's discharge instructions from the last ED visit and makes sure the patient understands those instructions and that the treatment plan is being followed.
The hospital works to see that the patients follow through with physician recommendations, take medications as prescribed, and take appropriate preventive measures, such as diet and exercise.
Often frequent fliers are stunned to realize what they have done. "It's eye-opening for them. For some, it is shocking that they have come to the emergency department so many times," says Selfridge, the St. Luke's case manager. For those who only had a slight injury or a cold, they are told they could have waited a day and didn't need to come to the ED.
Technology and diabetes
One academic report focusing on the ED of a county hospital noted an "excessive number of visits for diabetes complications, a high rate of hospital admissions from the ER, and the high cost of ER use."
That report was written in 1985. But the commentary is still relevant almost 30 years later, dramatically illustrating how long hospital officials have been grappling with the issue of ED use, particularly by diabetes patients, and especially those with lower income or limited access to primary care. In 2010, a study in Southern California showed that of 1,309 patients in two hospitals, about 11% were diabetic.
Healthcare systems increasingly rely on electronic medical records as a crucial step to keep these patients from going back into the ED, encouraging them to instead seek care elsewhere, such as with their primary care physicians.
Working with community organizations, the 681-licensed-bed Unity Health System in Rochester, N.Y., which is affiliated with the University of Rochester School of Medicine and Dentistry, established the Community Diabetes Collaborative to identify all of Unity's diabetic patients and their caretakers. The collaborative connects diabetics to providers through an interoperable platform that can accommodate all types of EMRs. The accumulated data enables physicians to keep a current record of diabetic patients' needs, says Margaret Donahue, MD, who recently retired as Unity's chief medical information officer.