ACEP: Frequent ED Users Need Coordinated Care

Emergency room physicians say overcrowding and visits from frequent users could be reduced with a coordinated approach to care.

The American College of Emergency Physicians released several studies Tuesday analyzing data about patients who visit EDs frequently. Robert O'Connor,  MD, FACEP, and ACEP board member as well as  Chair of Emergency Medicine at the University Of Virginia School Of Medicine in Charlottesville, says each study focuses on a different aspect of frequent ED visits, and as a result pointed to a difficult, complex problem.

"Despite the widespread belief that these patients can be easily redirected in the healthcare system for less expensive care, and that these patients are somehow abusing the system, the reality is much more complicated," says O'Connor.

Patients considered frequent ED visitors varied from study to study because each used a different definition. One California study considered a frequent user to be a one who visited the ED two to three times within six months, while another study in Wisconsin identified a frequent user as someone visiting an ED seven or more times within a year.

O'Connor did not express concern about the lack of uniformity among the studies. In some ways, it reinforces ACEP's position that frequent users are not abusers of the ED.

"Regardless of the definition, most studies found frequent users to be a very small percentage of the total number of emergency patients, although these patients did make a disproportionate share of emergency department visits," he says.

The study O'Connor authored, Characteristics of Repeat Emergency Department Users at a University Medical Center, found that frequent ED users made up 20% of all the patients, but nearly 40% of visits. Other studies had lower percentages of frequent ED visits, as O'Connor said, but those visits made up a larger share of the total.

For example, a study of all non-federal acute care hospitals in San Diego, Multiple Hospital Emergency Department Visits Among Frequent Users With a Pain-Associated Discharge Diagnosis, found that 8.5% of frequent ED users (those who presented more than four times within a year) made up 34.5% of ED visits.

Results of the studies also show that high repeat users, once admitted to the hospital, are more likely to require readmission, and that worries ACEP President, Andrew Sama, MD, because of the recently enacted rule than penalizes hospitals for 30-day readmissions.

"We need to focus on implementing plans to attempt to manage these patients better. What does that mean? Physicians, family members, social workers, and home care personnel have to work together and attempt to try to manage [patients] better and prevent them from being hospitalized," says Sama.

Despite varying definitions of who is a frequent user, the studies reveal a telling picture of who is a frequent ED visitor. It's patient who are likely to have limited access to routine healthcare and primary care physicians, which could keep them out of the ED. They're also likely to have a chronic illness, complicated health problems, and mental health emergencies.

The solution, says like the problem, is multi-faceted, says Sama, "This is not a single hospital problem. It's a community resource issue."

Sama says better access to mental health services would be huge step in diverting some of the patients from the ED.

Better coordination of care is also among the findings of a separate study of the Medicare population from the Medicare Payment Advisory Commission. MEDPAC found that 60% of ED visits were preventable, as well as 25% of hospital admissions.

The Centers for Medicare & Medicaid Services is attempting to address the issue. In June, the federal agency's innovation arm announced a $14.3 million grant to Rutgers University's Center for State Health Policy.

Over the next three years, the Center will work with hospitals in Pennsylvania, Colorado, California, and Missouri, to coordinate care for "hot spotters," patients who visit EDs four times within a year. The team-based approach involves nurses, social workers, and community health workers.

Model sites, all current safety net providers, include:

• Neighborhood Health Centers of the Lehigh Valley (NHCLV), Allentown, PA
• Metro Community Provider Network (MCPN), Aurora, CO
• Truman Medical Centers (TMC), Kansas City, MO
• MultiCultural Primary Care Medical Group (MPC), San Diego, CA

Rutgers estimates the model will save $67.7 million by diverting 2,500 high frequency ED users to more appropriate channels of care.