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How Coordinated Care Can Ground Frequent Fliers

 |  By jcantlupe@healthleadersmedia.com  
   June 07, 2012

One of the biggest problems for hospital leaders who run emergency departments are the "frequent fliers," those patients who repeatedly use the ED for ailments such as chronic back pain.  When they keep coming back, their overuse and inappropriate use of hospital services drains resources, money, and time that could be spent on other, more seriously ill patients.

It's not all the patients' fault. Far from it. The problem often originates with primary care physicians themselves, who steer patients to the ED, which is to say—they steer them wrong. 

As HealthLeaders Media reported this week, one in five patients who went to the ED but were not sick enough to require an inpatient bed, said they sought treatment in emergency departments because their primary care doctor told them to go there, according to a federal survey.

While some patients are referred to the ED, others "self-refer." They go to the ED because they feel they have nowhere else to turn for care, and not because it's the weekend, either. Apparently some primary care physicians are to blame for this scenario, too.

A number of these patients essentially have been "fired" by their primary care doctors for a host of reasons, such as missing too many appointments in succession, says R. Corey Waller, MD, a specialist in addiction and emergency medicine and director of the Spectrum Health Medical Group Center for Integrative Medicine, in Grand Rapids, Mich.

Waller spoke to me for an article  in May's HealthLeaders Media magazine that touched on the firing issue. Spectrum has targeted frequent fliers by steering them toward less expensive coordinated care.

When Waller uses the term "fired," he is referring to patients who are no longer welcome by doctors to have business with them. There has been much debate about "firing" patients, such as in pediatric cases when parents refuse vaccinations. It's a sensitive issue.

Medical associations say that should only occur in certain situations, when patients are abusive, or decline to pay bills, or yes, even when they continually miss appointments. In any event, patients should be given proper notification.

At the Spectrum Health Medical Group Center for Integrative Medicine, Waller told me, in an extensive interview, that he sees many patients who were dismissed by primary care doctors. "A vast majority of these patients have been fired from their primary care physician and sometimes from a federally qualified health center," Waller says.

Often, the patients have chronic pain, or have psychiatric or addiction issues. The clinic works to treat those patients and provide care to thwart the possibility that they may return to the emergency department, where many of them often end up after being dismissed by their doctors, Waller says.

Waller says he has checked with physicians' offices about why these patients were "let go."

"When I call the (physician) offices, and ask for the reasons (patients) are being fired, they say, ‘Well, they missed three appointments," Waller explains. " I say, ‘You are telling me these people who have no general transportation, no money for a bus, [so] they miss appointments … are going to get fired?''

"OK, they need to take responsibility for themselves, but what if they have an IQ of 70?" Waller asks rhetorically.

"And I see this every day," Waller says. "Most of my patients have been fired from physician practices at some point."

Waller tries not to dwell on the reasons why a fellow physician might fire a patient. There's a bigger problem after the patient is dismissed, he says. "Once (the patients) get fired, where do they go? The ED."

Being "released" isn't the only problem for these patients, Waller adds. From his vantage point, "a large portion of mental health diagnosis is inaccurate (for) these patients. They'll come up with being labeled for five to seven mental health disorders," Waller says.

"If you look at the definition of some of these illnesses, they simply can't co-exist, but these people keep getting labeled every time they show up (at their physicians' offices). You have them with a diagnosis of bipolar, but when you talk to them, yes, they have their ups and downs, but they just haven't been taught coping skills and they are angry."

Waller says the Spectrum clinic works to catch those patients before they keep going back to the ED. The doctor was instrumental in establishing the clinic after he led a study in 2008 about the "frequent fliers" at the hospital.  Waller found that 950 patients visited the EDs of two hospitals in the Spectrum system more than 10 times in a year. He extrapolated that these patients were responsible for as much of 20,000 total visits, and nearly $50 million in costs.

Those findings prompted Spectrum officials to design the clinic to identify, accurately diagnose and develop a care plan for the people who used the ED more than 10 times in a year. After initiating the program in late 2011, the program—in a matter of weeks—steered more than 140 patients from the ED into coordinated care and saved about $300,000.

"I would love to say this was borne out of altruism," Waller says of the clinic, "but it was borne out of frustration at the beginning, to be honest. There was just a feeling that there is a better way to do this."

Waller trained in emergency medicine at Thomas Jefferson University Hospital in Philadelphia. When he moved on to Spectrum, he was seeing the same types of patients who needed help, who needed proper follow-up care, but weren't getting it. Too many patients were "blown off as mentally deranged," he says. "At the end of the day, they had to live in that situation." Naturally, they kept returning to the ED.

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, and with increased follow-up planning and coordination with primary care physicians, Waller says.

Each new patient undergoes a series of evaluations that includes a comprehensive exam by a physician, a behavioral health evaluation by a mental health professional, an addiction assessment, and intervention by a social work case manager. A care manual is then provided for each patient seen for a three- to six-month period to monitor his or her progress.

"A case manager can make sure they have housing, heat, a pathway toward getting a job," Waller says. Spectrum has partnered with Grand Rapids Community College to help people who may not have finished college, or who seek to be in a training program.

"A high percentage of patients, once stabilized, don't require this intensity of care. We want to make sure we have an accurate diagnosis and mental health assessment, and an accurate assessment of their social situation," Waller says.

It's at that point they could have a successful "handoff" to a primary care physician.

So, good outcomes rely heavily on physician involvement. Sometimes, the doctor comes on board a little late, but the Spectrum program shows that primary care is a key to reducing negative impacts on the ED, and eventually improving patient care.

Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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