Grounding the Frequent Fliers
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With a focus on individuals and families as well as population health management, CareOregon also is working with healthcare systems to improve coordination and reduce emergency department visits. The Portland, Ore.–based nonprofit health plan is involved in delivering care to Medicaid patients through five different coordinated care organizations in Oregon and includes 8,000 primary care providers and specialists, 43 hospitals, and 34 public health departments.
Last year, CareOregon mapped patients with high healthcare needs to identify key commonalities among patients. "We did a lot of multidisciplinary team building in order to find the behavioral drivers of high utilization," says Rebecca Ramsay, BSN, MPH, director of community care for CareOregon.
"We needed a pretty wide net, with primary care teams spending 60% to 70% of their time making home visits," she says. "It's boots on the street." At least four outreach workers supported 46 patients, and within six months reduced the patients' ED visits by 31%. "Our community outreach workers have told us that when they engage with a patient, they are essentially acting as an extension of the primary care team that goes into the community," Ramsay says. "The patients gain so much support from this approach that they often don't need to come into the office for care as frequently."
Changing behaviors is essential. In 2011, the 349-licensed-bed Good Samaritan Hospital in San Jose, Calif., opened a $30 million ED that includes 42 private rooms, six fast-track rooms for minor injuries, and a separate express care area for less serious conditions, such as sore throats, in an effort to speed up diagnostic testing and treatment.
These architecturally based changes along with revamped care coordination have shown good results, according to Hospital Compare. At Good Samaritan, the average patient wait time to be seen by an ED professional staffer was 20 minutes in the first quarter of 2012, far below the national average of 30 minutes and the California average of 33 minutes.
Still, the Good Samaritan ED isn't perfect: The average time a patient spends in the ED before being sent home is 168 minutes, 5 minutes fewer than the California average, but greater than the national average of 140 minutes.
One of the biggest problems for the hospital is an aspect of the frequent flier that Good Samaritan sees often: patients who are looking for certain prescription drugs, and they drop in to get them. "It's a pretty significant problem," says Ellis Weeker, MD, vice president of CEP (California Emergency Physicians) America in Emoryville, and an ED physician at Good Samaritan.
Many of the patients who frequent the EDs for this reason have pain issues, and some already have been prescribed medication from their doctors. To help resolve those issues, Good Samaritan has developed a quality assurance process to create a care plan and coordinate it with patients' primary care physicians to thwart potential medication abuse, Weeker says.
No cure yet
As Townsend, the CEO of St. Luke's, sees the issue of frequent fliers, he has hope, but also concerns. While the hospital has drastically reduced repeated use of the ED by a select group of frequent flier patients, it has only scratched the surface, he says.
"The volume in the ED went up last year, even though we found a better way to take care of these frequent fliers. The story is very much the same around the country; it's an issue that will stay," he says. "It will be an issue for years to come."
While St. Luke's has successfully steered more than 100 frequent flier patients away from the ED toward alternative care, the hospital estimates that hundreds more may be eligible to become frequent fliers within the next year or so.
"We're starting to put the hospital and physicians in a position to coordinate care whenever that care may need to occur," Townsend says.
Dealing directly with the patient and discussing the need for change can produce results. A 50-year-old St. Luke's patient who frequented the ED admitted he had limited options for a primary care physician because he caused such a fuss in his physician's office that he was no longer welcome. The hospital worked to connect the patient with a new primary care physician.
"Several months passed. The patient had not returned to the ED, and one day he called me to 'check in'," recalls Selfridge, the social worker at St. Luke's. "He let me know he had found a physician in town that accepted him as a patient and he wanted to let me know that he was keeping our conversations in mind and things were going well."
Joe Cantlupe is senior editor for physicians and service lines for HealthLeaders Media. He may be contacted at firstname.lastname@example.org.
This article appears in the April 2013 issue of HealthLeaders magazine.
Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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