Patient Flow E-Newsletter
Volume 3, Issue 3
Wednesday, October 25, 2006

Innovations
Helping Frequent Users of Emergency Departments Find Their Medical Home

When BryanLGH Medical Center was selected as one of 10 hospitals nationwide to participate in the Urgent Matters learning network three years ago, hospital officials thought they might gain insights into improving their internal processes and reduce crowding in the emergency department (ED). Little did they know that three years later, BryanLGH would be working hand in glove with its chief competitor to help vulnerable people throughout Lincoln, Nebraska, improve the effectiveness of their care and find their medical home.

But when an assessment of Lincoln's safety net, prepared by the Urgent Matters staff, showed that ways to link safety net patients with community providers was lacking - and that 35 percent of ED visits were non-emergent - community leaders knew something had to change.

The result is Lincoln ED Connections, a cooperative effort between Saint Elizabeth Regional Medical Center and BryanLGH. The program helps coordinate care for people in Lincoln who are most in need and who previously turned to local EDs repeatedly for their medical care. It helps vulnerable people with chronic medical or mental health issues better understand available services in the community by providing access to appropriate medical providers, information on insurance coverage options, needed medications and referrals to other community services.

"There are many reasons people turn to the ED for their care even when it's not a medical emergency, but one big reason is that people who do not have insurance have difficulty accessing primary care," said Libby Raetz, Emergency Department Director at St. Elizabeth. "Maybe they have trouble navigating the waters to find a medical home, or have limited abilities to speak English. Maybe they don't know if they are eligible for public programs or how to enroll. Whatever the reason, we came to see the lack of coordinated care for this population as a community-wide problem that manifested itself in the ED. The goal of ED Connections is not just to improve our patient flow and reduce crowding in the ED, it is to help these patients manage their own care and use the community resources that are available to them."

Funded with $300,000 in grant money from the Community Health Endowment in Lincoln, the program identifies patients who regularly come to any of the city's hospital emergency departments for non-emergent care and matches them with appropriate resources in a very hands-on way. By formalizing a case management network among the two hospitals, staff at both sites can easily identify individuals who meet the eligibility criteria, and visit Lincoln's emergency departments three or more times in 6 months. With this information the ED Connections staff can help coordinate their care in more appropriate ways.

"Obviously we wanted to make our EDs function as efficiently as they can and be available for any patient who needs emergency care. In order to do that, we had to reduce crowding so that we were not on diversion," said Ruth Radenslaben, Clinical Director for BryanLGH. "Through Urgent Matters' assessment of our community safety net, and the leadership of the Community Health Endowment, we were able to accomplish our goals while helping to build a continuum of care for the patients who need it most."

Early results are impressive. The hospitals have seen a 60 percent decrease in ED visits from program participants, when comparing ED visits for six months prior to enrollment with the six-month period post-enrollment. Based on this information, the reduction in charges for these patients - most of which are uncompensated is $217,000.

How it Works
Before launching the program, staff from BryanLGH and St. Elizabeth worked together to identify criteria for patients to participate. The patients all had high utilization of the community's EDs, and used the EDs for non-emergent conditions. They generally lacked health insurance and did not have the skills to maneuver through the process of finding resources to meet their many needs.

Now that the program is operational, when a patient meeting the agreed-upon criteria is referred by ED or other staff, newly hired case managers contact the patient sometime during or after treatment to talk about the ED Connections program. They explain that the hospitals in Lincoln want to help them coordinate their own care, follow up on treatments, access the medications they need and take advantage of the community services available to them. Patients who agree to participate in the program are immediately enrolled and provided with resources and a network of hands-on providers who agree to see the patients. A patient "contract" has just been initiated to better assure their understanding and compliance with their plan of care.

Their patient information is also enrolled in a database that can be accessed at either hospital, so staff at both hospitals can better coordinate a patient's care if he or she arrives at the emergency department. Staff also follow up after the ED visit, helping the patients set goals for managing their care, or understanding when a visit to the ED is appropriate.

Planning Process
The hospitals took a full year to plan Lincoln ED Connections and view the time spent as key to the program's success. Working with the Community Health Endowment, they met with various hospital staff, doctors, business leaders, social service providers, government agencies, etc.

"It seemed like a long time, but now I think a year of planning was time well-spent," said Raetz. "Putting the infrastructure in place was important, and we needed to involve ED staff, marketing, medical records staff, our information technology people - plus develop forms, logos, operational procedures and hire the case managers. There was a lot to do and we worked quickly, but we were thorough. And we built a lot of trust during that year, too."

Both hospitals agree that having support from senior management and directors from each facility working together to design and implement the program has been a key to its success. They view the year of planning as important to building the trust and communication necessary to keep the program going.

"By the time the year of planning was through, we were working together as collaborators, not competitors," said Radenslaben.

Community Reaction
The hospitals are starting to survey program participants, ED staff, physicians and others about their reaction to ED Connections, and anecdotal reports are encouraging. Doctors say the new program has improved the quality of the work in the ED, as well as the quality of care the most vulnerable patients receive.

Community resources in Lincoln, along with the Community Health Endowment and social services agencies, are pleased that more patients are accessing primary care programs, or even turning to them for help with food and housing issues.

But it is the reaction from many of the patients that has been most gratifying.

"The reaction from the patients has been especially positive," said Radenslaben. "Some of these patients were coming to the ED all the time and didn't even know that there were other possibilities, that they actually could get coordinated care. When patients come to the ED, they are treated as if they are in crisis mode. We can fix that crisis and send them home, but if they cannot manage their illness, then there would be another crisis. Now we've shown them another way and helped them understand their medications and coordinate their care. We've taken them out of the circle of one crisis after another."