Emergency Rooms are often the catch-all of the medical world, where patients can receive care at any hour, regardless of their ability to pay.
But physicians and hospital administrators say it’s an expensive and disjointed way for people to receive care, particularly when patients visit the ER multiple times a year.
A pilot program to manage care for ER ‘super users’ in Cedar Rapids is now in its third year—and administrators say it saves St. Luke’s Hospital about a million dollars annually.
Coordinating Care for Multiple Diagnoses
At her home in Cedar Rapids, Theresa Brown flips through a calendar where she tracks her doctor’s appointments and medications for diabetes, asthma, and COPD—a chronic lung disease.
“This is what Sallie made,” she says, referring to her case manager at the St. Luke’s Hospital Emergency Department. “You call your daily weight in to the Heart Failure Clinic, they let me know whether to take…. an extra water pill.”
There are six doctors and 36 medications on the calendar. Brown says that before she was able to control her diagnoses, she’d find herself in the emergency room once a week.
“I threw my meds away, I didn’t care anymore,” Brown said. “I was tired of going through this, the pain. I’d end up in the hospital because everything goes bad when I don’t take my medication.”
According to a study of Medicaid claims and encounter data in New York City, published in Health Affairs, 63% of people who visited the Emergency Department more than 15 times in the year 2007 were diagnosed with multiple chronic conditions—84.5% had at least one.
Brown is exactly the kind of person that hospitals try to reach through coordinated care programs. By assigning a case manager to help Brown coordinate doctor’s appointments and access preventive care, her illnesses become an emergency less frequently—and Brown says she’s starting to see her health actually improve for the first time in years.
Coordinated Care for a Few, With Lower Costs Overall
St. Luke’s Hospital in Cedar Rapids is one of the busiest Emergency Rooms in the state, logging more than 55,000 visits each year. Employees noticed that a disproportionate number of visits were from a small group of frequent users.
Sallie Selfridge is the program case manager for the Emergency Department Consistent Care Program at St. Luke’s. She says that as coordinators began tracking visit histories through the hospital’s electronic medical record, they found a number of factors for why patients visited more frequently.
“For some it’s been no insurance. Transportation can be a barrier. I thought we’d have more patients without primary care providers, but that wasn’t the case, it’s just they weren’t utilizing them,” Selfridge said.
In 2012, Selfridge started developing preventative care plans for 103 patients who visited the ER more than 12 times a year. She coordinated with patients’ primary care providers to make sure the care a patient received in the ER matched their long-term care.
“Best example I can give is I have a gal that had 16 ED visits in two months, all for migraines,” Selfridge said. “When I talked to her family physician, the first thing he told us was not to give her narcotics in the ED, because while initially it would take away the headache, it was causing more severe rebound headaches.”
Within a year, those 103 patients collectively reduced their ER visits by two-thirds. Selfridge says they’ve been enrolling about 10 new patients each month.
“Ultimately, the goal of the program is not just to reduce those ED visits. We really want folks to get their medical needs met, just in the most appropriate settings,” Selfridge said.
Today, the program has 390 people enrolled. Emergency Physician Josh Pruitt, who sits on the coordinating committee for the St. Luke’s program, estimates it’s saved the hospital $2.85 million dollars in facility costs alone.
“It’s a problem across the country. People see these visits increasing, of people that really can be better cared for in an outpatient setting, with less expensive services provided by primary care physicians,” Pruitt said.
Pruitt says it shows a shift in how hospitals serve patients who otherwise might be a burden on the system.
“I think for so long we just thought, that’s just part of the job and who people are,” Pruitt said. “There’s different things we can do to intervene with these folks.”
The Possibility of Expansion
Because the Affordable Care Act includes incentives for hospitals that keep costs down, hospitals are looking at these coordinated care programs as a way to adapt. UnityPoint will use St. Luke’s program for multiple hospitals in their network, which reaches throughout Iowa and into Illinois—and Selfridge says she’s been contacted by other hospitals outside Iowa for more information about their model.
UnityPoint is also implementing care coordination programs for people with multiple complex diagnosis and building on an existing program for palliative care for people with serious illnesses.
Chief Clinical Officer Monique Reese says 250,000 UnityPoint patients are now part of value-based payment systems, instead of fee-for-service.
"With the Accountable Care Act and some of the changes, it's really beginning to set up so care is delivered in the community, and we're proactive in caring for patients," Reese said.
In addition, UnityPoint's Palliative Care program—which focuses on treating symptoms and improving a patient’s quality of life after a serious diagnosis—has reduced Emergency room visits for their patients by 54%.
Edit 4/11: A former version of this story used the word "preventative" instead of "preventive care." A quotation from Reese was also added.
