This article appears in the April 2013 issue of HealthLeaders magazine.
They come into the emergency department as if it's their second home; indeed, they often are on a first-name basis with the medical personn el who are there to greet and treat them. On this particular Sunday night in a suburban Washington, D.C., hospital, a patient is in the ED, smiling but with a bloodied face. A nurse whispers in the hallway: "Mary's alcohol level is high again." Just as the bartenders at the local taverns do, the ED nurses know Mary. She is a regular. Scenes like this one are being played out regularly across America, like well-worn reruns.
Theodore I. Benzer, MD, PhD, FACEP, is chairman of ED quality and safety and director of clinical operations for the department of emergency medicine at Boston's 907-licensed-bed Massachusetts General Hospital. He sees and treats many of the patients who return to the ED time and again—at least five to 12 times a year or more. "They are so near and dear to us," Benzer says. "This is our group of patients we feel we know."
These are the so-called frequent fliers, a broad term that covers patients with varying needs. Some of these rebounders are challenged by alcohol or drug abuse issues or they need mental healthcare. Others choose the ED because they have no health insurance or primary care physician. Some are driven by fear and suffering associated with chronic pain but are reluctant to make an appointment to see their primary doctor—or their doctor is reluctant to see them yet again.
"We have very much longed for the opportunity to see new ways of taking care of these patients … to meet their needs, but in less and less costly ways," says Ted Townsend, president and CEO of the 250–300-staffed-bed St. Luke's Hospital in Cedar Rapids, Iowa, which has been working to reduce frequent fliers' usage of the ED. "We need to intervene with these patients in a different way."
The urgency of grounding frequent fliers has prompted hospitals, healthcare systems, and academics to initiate strategies to curtail what many believe will become more of an acute problem. Insurers are working with hospitals to implement programs for mentally ill patients and others with chronic conditions in an attempt to divert the patients into hospital-sponsored coordinated care plans that connect with government and community organization–provided services. Case managers closely monitor frequent fliers by following up after ED visits to prevent recurring hospital stays. Hospitals are installing electronic medical record programs that may flag frequent fliers for primary care physicians and community organizations.
Hospitals are assigning nurses and social workers to pore over records to identify patients who come to the hospital too often and actually are alerting the patients themselves that they may need primary or psychological medical care, not another trip to the ED.
"Each month, we review the frequent fliers, and some who are even very frequent fliers, the patients who come five or six times a month," says Benzer. Whether the patients use the ED five times a year or five times a month, he says, "Over the years, we've found what other hospitals are finding: A lot of these patients have drug, alcohol, or substance concerns, and there are some who are homeless."
Also, there are patients who repeatedly use the ED who have "very severe and complex medical problems," Benzer says. "It's very complicated. The sad part in all of this is that, in medicine, in terms of treatment, it's not easy. It's not like giving penicillin for strep throat; there's no 100% cure." Patients "may be drunk, but drunk people have heart attacks and skull fractures. When they get drunk they can't tell you how they are feeling."
Because of the complexities involved with ED frequent fliers, MGH has been coordinating programs with city and state social service organizations with a simple goal: "We can get them into a program rather than the ED," Benzer says.
For hospitals, frequent fliers are a strain not only because of the high cost of running the ED, but because repeat users add to overcrowding and wait times that impact patients with emergent care needs. Better treatment of this population has never been more urgent for hospitals, what with reimbursement changes away from fee-for-service and upcoming 30-day readmission penalties from the federal government. As more elements of the Patient Protection and Affordable Care Act get implemented, emergency medicine physicians expect the use of EDs to increase when as many as 40 million previously uninsured people flow into the system.
Throughout the country, frequent fliers are impacting hospital EDs in varying degrees. As reported in a series of studies in 2012 for the Annals of Emergency Medicine, frequent fliers at hospital EDs sought emergency care at least four times a year and sometimes as often as 21 or more. Individual patients can account for one or two dozen visits, sometimes more. In 2010, the Department of Emergency Medicine at Mount Sinai School of Medicine in New York reported that frequent users comprised 4.5%–8% of ED patients, but accounted for 21%–25% of all hospital visits. A 2010 Rand Corp. study reported healthcare spending of $4.4 billion on people using the ED for routine, nonurgent care.
"There is a small population driving costs in the system, which given its fragmentation has not been well designed to meet the complexity of their needs," says Allison Hamblin, MSPH, vice president for strategic planning at the Center for Health Care Strategies, a nonprofit health policy resource center based in Hamilton, N.J. "But the pendulum is swinging. We are starting to see more organized care and more integrated programs for these patients with complex needs."
Case manager plan
The frequent flier issue was exemplified at St. Luke's, where a Cedar Rapids woman took the bus—almost as a commuter would, with no sense of urgency—to make 12 visits to the ED in 2011, says Sallie Selfridge, a case manager in the hospital's ED, which logged 55,079 emergency visits that year. Although the patient had congestive heart failure—a chronic condition—there was nothing urgent about the elderly woman's visits.
Hospital executives started to evaluate the process after a social worker and nurse practitioner began comparing notes, saying, "Did you see Fred was back in the ED again today?" Townsend recalls. "The fact they could actually know who these people were on a first-name basis seemed incongruous to the emergency department," he says.
St. Luke's Hospital began a consistent care program to identify frequent fliers who returned to the ED for at least 12 visits in 12 months. The solution is giving these patients assistance in locating alternative care. The effort has been successful in reducing patient trips to the ED. In 2011, 103 patients who were designated frequent fliers made 1,679 visits to the ED. But after involving the patients in coordinated care planning, within a year the same group made only 537 visits.
At St. Luke's, they found that many of the patients use the ED because they don't have a family doctor, and others have difficulty keeping appointments because they lack transportation, have work schedules that make it tough to visit a doctor during office hours, or have financial or insurance issues.
"We wanted to identify these frequent fliers and put together a plan of care for each of these individuals to see if we can find a way to reduce their utilization of the ED—not just to avoid the ED but to get them to more appropriate levels of care, and that's exactly what happened," says Townsend, the CEO.
As hospital officials examined the frequent flier situation, they focused on the financing, and it "came out as a wash," he says. By eliminating the income to the ED with the decrease in frequent fliers, the hospital estimated that it lost about $500,000 in one year related to patients who were diverted to other care.
At the same time, the hospital estimated it saved about half a million dollars by not having to provide additional care and testing for such patients, Townsend adds. "In reality, because of the payer mix of folks coming through the ED, that was roughly a break-even proposition for St. Luke's," he adds. "Yes, we would have generated $500,000 in fees, but we probably were incurring $500,000 in costs; it was a zero-sum game," he adds. "It's the right thing to do for the community and works reasonably well for St. Luke's."
Creating a direct relationship
As Benzer points out, even in Massachusetts, where health insurance is universal, frequent fliers are prevalent at hospital EDs. "Almost all of these patients have been identified as having primary care physicians, and they had insurance, so that wasn't the issue," says Dawn Williamson, RN, MSN, PMHNS-BC, an addiction specialist in the ED at MGH.
Staff physicians and nurses at MGH reviewed their records and formed a team to coordinate various programs for the frequent fliers, or, as they dub them, MVPs or multivisit patients.
"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.
To eliminate gaps in care for diabetic patients, Donahue says, the hospital uses electronic records to identify patients in need of care. While the hospital had tried for years to reduce dangerously high levels of hemoglobin-related blood sugar counts among patients, it recently improved its care in this area, she says.
"They were not getting the care they needed," she says bluntly of diabetic patients. For instance, some patients hadn't checked their hemoglobin levels in six months, says Donahue. In the ED, patients wouldn't know the medications they were on. "We saw an opportunity to identify these patients, get their hemoglobin tested, record their medications, and analyze this information." Continuity from the patients' electronic records coupled with improved care management enabled the hospital to convince patients how important it is to check their hemoglobin levels and maintain improvements in their care.
With dbMotion interoperability software, the hospital has been able to maintain a "master patient index to identify patients between the different EMR systems and consolidate and semantically map the data from across the systems," Donahue says. "We have the data from both hospital and office EMR systems to identify those gaps." Donahue says the hospital's "access to the patient's medication history is greatly improved with access to the [software] and to external medication history through e-prescribing."
Behavioral care and insurers
In Pittsburgh, the proximity of a number of hospitals to each other means that sometimes patients decide that they can take their pick of emergency departments.
A Pennsylvania medical assistance program is seeking to integrate physician and behavioral health services for adults with serious mental illness and physical health comorbidities, directing its efforts at patients who frequent the ED and are often readmitted to the hospitals. Pittsburgh-based UPMC—a $9 billion global health enterprise with 21 hospitals, 400 doctors' offices and outpatient sites, and a health insurance division—is involved in this effort.
Behavioral and physical care systems often lack coordination, which can result in negative impact on individuals, according to James Schuster, MD, MBA, chief medical officer for community care at UPMC's insurance services division.
The program, Connected Care, involves UPMC's Medicaid managed care plan, UPMC for You. From July 2008 through April 2011, the program enlisted more than 2,500 of 8,600 Medicare members in a pilot study. UPMC for You and Community Care Behavioral Health, based in Pittsburgh, launched the test for the Pennsylvania Department of Public Welfare to integrate behavioral and physical healthcare Medicaid services for people with serious mental illness. The organizations worked with other stakeholders, such as behavioral health and physical health systems in Allegheny County, which includes Pittsburgh. By coordinating care and using electronic medical record reviews and case manager follow-up, officials of the UPMC Health Plan say Connected Care has significantly reduced mental health readmissions to hospitals and has shown promise to reduce ED use.
The Connected Care plan involves a multidisciplinary team that holds clinical case reviews for patients with "complex needs." The team, which meets twice a month, includes the health plan's medical directors, care or case managers, clinical supervisors, and UPMC pharmacists. Then UPMC care managers educate the patients on how to manage their physical condition, prevent unnecessary ED visits, and follow up within 24 or 48 hours of a hospital readmission or ED visit.
"The effort required some IT and clinical process development work. This is now complete and the incremental cost for expanding this program to additional regions is expected to be nominal," Schuster says.
The all-cause readmission hospital rate dropped from more than 43% to nearly 39% for the study group from 2007 to 2011, Mathematica Policy Research found. Its report stated that Connected Care "holds promise for improving ED and mental health hospitalization rates." Too often, there are not enough programs to assist patients who simply use the ED as a "kind of urgent care center," says John Lovelace, MS, MSIS, president of government programs and Individual Advantage for the UPMC Health Plan. "Some people don't take advantage of psychiatric care. There is a proportion of people who do not go see a primary care doctor. They don't do anything."
Coordination is impacted by what may seem like the simplest of flaws, Lovelace says. "A lot of times, the ambulatory provider or behavioral health person doesn't know someone was in the ED because the patient doesn't tell them, or they may not see them very often," Lovelace says.
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. Revamped care coordination has shown good results for the 349-licensed-bed Good Samaritan Hospital in San Jose, Calif, 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.