Emergency Department Strategies

HealthLeaders Media Council members discuss what's driving the increasing patient volume in their ED, and how they plan to handle it.

This article first appeared in the November 2016 issue of HealthLeaders magazine.

Paul Hensler
CEO
Garfield Medical Center
Monterey Park, California

Our organization is expecting increased volume. A lot of it is driven by Medi-Cal—California's Medicare program—expansion, and we treat a lot of capitated lives as well.

We've always had a significant share of Medi-Cal patients, but with Medi-Cal expansion, the patient population has changed. Medi-Cal was once largely a program for moms and kids; the expansion brings in a lot of middle-aged men, and within that group there are a lot of mental health issues, drug issues, and probably more issues with homelessness. So that's part of the new volume.

Disposition is a challenge when dealing with homeless patients. We can't send them home if they don't have one. We've contracted with shelters that have programs that not only give homeless patients a place to live—at least for a couple of weeks while healing—but also have some nursing care available.

When the weather gets really hot or when it's raining, some people who are homeless decide the ER is a good place to hang out, which can be a challenge for us. We've instituted fast tracking in the ER; we can quickly evaluate them, a medical decision is made, and if they don't need medical attention, they can be quickly discharged.

William Cors, MD
Vice President and Chief Medical Officer
Pocono Medical Center
East Stroudsburg, Pennsylvania

We don't expect an increase in volume, we are living the increase right now. We are doing about 78,000 emergency room visits a year now. That's up about 8%–9% from the previous year.

We have a three-part strategy. The first part is the emergency room itself. We just finished a nearly $4 million renovation and have added 13 additional treatment spaces. They're mostly for what we call vertical patients: patients requiring minor care. We have found that much of the increase in volume has been patients with minor care needs.

Second, we've opened up immediate care centers that are staffed by nurse practitioners. We currently have four of them in the region that we serve, and we're looking at opening an additional one or two. We thought that would help decompress the emergency room, and it might have in its first year—visits went down in the emergency room a bit.

But, over the past two to three years, we've not only seen the volume in the emergency room increase but we've seen volume in each of our intermediate care centers go up, too. If you add the two of them in aggregate, we are probably seeing close to 100,000 patients in more of the acute care medium-sized settings, whether it's an emergency room or an immediate care center.

That said, in our final strategic change, we placed primary care positions at key points throughout our service area. We have recruited 12–16 new physicians and nurse practitioners. But, despite increasing access, volume still continues to increase across the board, in all care settings.

John Sigsbury, MHA
President
SSM Health St. Mary's Hospital
Centralia, Illinois

Our hospital is in rural southern Illinois. As in many southern Illinois communities, we have not seen any population growth. In fact, in the last decade, we have seen our population decline as many jobs have moved out of the region.

Many of our local physicians are in independent practice and in their late 60s or early 70s, and are starting to reduce the scope of their practice and hours worked. In addition to these two factors, we have not had any expansion or construction in our hospitals emergency department in quite some time.

Instead, our strategy has been to open freestanding urgent care centers in the community. They are fully aligned with the hospital, our parent company SSM Health, and our medical staff, but they are freestanding. We have been able to bleed off some of the lower-acuity patients from our ER, seeing them now in urgent care instead of in the ER.

This works for us because, as the independent physicians start to age out of their practices and make themselves less available for their patients, we're still providing access points. It's not a strategy that anticipates an increase in ER visits, but we are seeing an overall increase in ambulatory visits, mostly through our urgent care centers. We still want these patients being seen in urgent care centers to be part of the healthcare system, so we are now focusing on recruiting additional primary care physicians into our medical group.

Jane Curran-Meuli
Chief Operating Officer and Executive Vice President
Holy Family Memorial
Manitowoc, Wisconsin

On accommodating mental health patients: There are not a lot of resources for treating mental health patients in our community. In Manitowoc county, there is no inpatient behavioral health unit at all. We do have outpatient behavioral health, but demand exceeds what we can provide. Some people come in with severe problems that are simply beyond our scope of practice.

One thing the state of Wisconsin has done recently is that hospitals have worked collaboratively to create a website that lists all available behavioral health beds throughout the state. This saves us from having to call from institution to institution to see if they can take a patient. Now, we can just go down the list and see if there's a space, and then call hospitals with available beds. It saves a lot of time and takes a lot of work off our providers.

On paying for emergency care: One of the chronic conditions in healthcare these days is people needing care and not having the funds to get it. The exchanges helped quite a bit, but this community also has a process where a local credit union helps patients take out loans to pay for the care they need. The credit union pays us in full, giving the patient the means to pay.

We are the guarantor of the loan and pay the credit union if the patient defaults, but that rarely happens. Most patients truly want to do the right thing and pay their bills, but these expenses can have a huge impact on a family.