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4 Keys to a Better Emergency Department

Joe Cantlupe, for HealthLeaders Media, June 8, 2012

Success key No. 3: Frequent fliers
For EDs nationwide, one of the biggest problems is "frequent fliers," those patients who repeatedly use the ED as an alternative to primary care. Many of those patients need psychiatric services or should be seen for alcohol or drug abuse conditions.

Too often, those patients are dismissed by their primary care physicians for failure to follow instructions—and are "fired" by the practitioners, says R. Corey Waller, MD, a specialist in addiction and emergency medicine and director of the Spectrum Health Medical Group Center for Integrative Medicine. Most of the patients have been diagnosed as having mental health or substance abuse issues or poorly controlled medical issues, such as diabetes, or pain issues that "were never fully vetted or diagnosed," he says.

Spectrum Health, based in Grand Rapids, Mich., had initiated the program in late 2011 after identifying nearly 1,000 patients who used the ED at 847-licensed-bed Spectrum Butterworth and 284-licensed-bed Blodgett hospitals more than 10 times in a year. By focusing on these patients, Spectrum has channeled them to cheaper care programs and away from the ED, with hundreds of thousands of dollars saved, Waller says.

Under the program, physicians ask the patients if they would agree to coordinated care treatment; most of the nearly 200 patients contacted early this year said they would. The center's treatment team uses addiction specialists, RN case managers, and medical social workers to evaluate the medical issues, such as pain or diabetes, but also addiction or alcohol abuse that may be driving patients to the ED.

"Of the patients in our system, more than 60% have been preidentified as having been engaged in our local mental health system and substance abuse service," Waller says. Those patients accounted for more than 20,000 total visits and up to $50 million a year in costs to the hospital system. The program was started after he began seeing the same type of patients and it became frustrating, Waller adds.

At least 40% of the patients are neurobiologically addicted to some substance. Through a regimen that combines medication and behavioral therapy, at least 90% have stayed clean since starting treatment, he adds.

When patients "show up here, we have a four-hour initial visit in which they see a case manager, a social worker, and myself," Waller says. "We look over the last five years or more of their records to determine what's been done, what hasn't been done, what's been missed, what's been diagnosed."

Over time, Waller encourages the patients to work with primary care physicians, beginning with phone consultations. Often, those physicians can "identify previously undiagnosed illness," he adds.

"The hardest part is getting these people placed into appropriate therapies," he says. "The goal is to come up with a screening tool so we can identify them and get them the social or psychological or medical services they need before they turn into a high-frequency user of the ED," Waller says.

In that way, he says, the cycle of patients going to the ED is curtailed.

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1 comments on "4 Keys to a Better Emergency Department"


Matthew Shafiroff, MD (6/8/2012 at 12:51 PM)
All great ideas. Tremendous focus on the front end problems in the ED. Diverting patients to other resources will be a necessary strategy if the individual mandate clause of the PPACA is upheld. A great follow up article would examine the process (work-up) and back end problems in emergency departments. For example, Many EDs are being superb at managing front end problems only to be failed on the back end where admitted patients languish in the EDs for hours after being admitted. This effectively decreases the number of 'active' beds in the ED, contributing considerably to longer wait times in the late afternoon and evening.