BACKGROUND: In 2008, Kern Medical Center established a Care Management Program (CMP) for low-income adults identified as frequent users of hospital services. Frequent users are defined as having 4 or more emergency department (ED) visits or admissions, 3 or more admissions, or 2 or more admissions and 1 ED visit within 1 year. The CMP helps patients access primary care and medical and social resources.
OBJECTIVE: To determine whether the CMP reduces ED visits and hospitalizations among frequent users.
METHOD: Between August 2007 and January 2010, a retrospective analysis was conducted using Kern Medical Center encounter data. ED visits and inpatient visits were compared pre- and postenrollment for care managed patients (n = 98). The analysis included a comparison group (n = 160) of frequent users matched on the basis of race and age. Multivariate analyses were performed to evaluate the difference in utilization between groups, and to adjust for potential group differences.
RESULTS: There was a reduction in the median number of ED visits per year from 6.0 ± 5.0 (median ± interquartile range) pre-enrollment to 1.7 ± 3.3 [corrected] postenrollment (P < 0.0001). The difference in inpatient admissions pre- and postenrollment was 0.0 ± 1.0 (P < 0.0001). After adjusting for multiple factors, multivariate analysis demonstrated that care managed patients had a 32% lower risk of visiting the ED than the comparison group (P < 0.0001). There was no difference in inpatient admissions between groups.
CONCLUSIONS: CMP that helps patients navigate the health care system and access social and medical resources show significant promise in reducing ED utilization.
OBJECTIVE: Emergency department (ED) frequent users account for a large number of annual ED visits and often receive radiological studies as a part of their evaluation. We report a pilot study of a case management program for ED frequent users to reduce ED usage and radiation exposure.
METHODS: This observational retrospective study was performed at a community hospital ED. Between May 2006 and April 2008, 96 patients were enrolled in a case management program and were followed through November 2008. The case management program consisted of a multi-disciplinary team of physicians, nurses, social services and specialists in pain management and behavioral health. Patients were enrolled if they had five or more visits to the ED in the previous month, if a concern about a patient's ED use was raised by staff, or if they were identified by the California prescription monitoring program. Case management addressed specific patient issues and assisted with receiving consistent outpatient care. The number of ED visits per patient and the number of radiological studies at each of these visits was recorded. When reviewing data for analysis, we used the number of total images in all computed tomography (CT) scans during the given time period.
RESULTS: In the six months prior to enrollment, patients averaged 2.3 ED visits per patient per month. In the six months after enrollment, patients averaged 0.6 ED visits per patient per month (P<0.0001), and all visits after enrollment up to November 2008 averaged 0.4 visits per patient per month (P<0.0001). In the six months prior to enrollment, these patients averaged 25.6 CT images per patient per month. In the six months after enrollment, patients averaged 10.2 CT images per patient per month (P=0.001), and all CT images after enrollment up to November 2008 averaged 8.1 CT images per patient per month (P=0.0001). This represents a decrease in ED use by 83% and a decrease in radiation exposure by 67%.
CONCLUSION: Case management can significantly reduce ED use by frequent users, and can also decrease radiation exposure from diagnostic imaging.
AIMS: To assess whether case management of frequent attenders to the emergency department (ED) reduces subsequent attendances made by these patients.
METHODS: Patients who attended the ED 10 times or more over a 6-month period were identified. Their cases were assessed and care plans put in place, if appropriate. Patient attendances over the subsequent 6 months were compared.
RESULTS: 57 patients attended the ED 10 times or more over the 6-month period (1.4% of the departmental workload). The median number of ED attendances in this patient group was 12.0 (interquartile range (IQR) 10-14). In the subsequent 6 months following case management of these patients, median attendances in the same 57 patients dropped to 6.0 (IQR 2-13, p<0.001). The total number of attendances in this patient group dropped from 720 to 499, a reduction of 31%.
CONCLUSIONS: The findings of this study suggest that individual case management and implementation of care plans may help to reduce subsequent attendances in patients who frequently attend ED.
Report»California State University, Sacramento - Department of Public Policy & Administration
Year»2008
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Emergency department (ED) overcrowding is a persistent problem. The Care Connection Program (CCP) is designed to educate frequent users on how to better use existing community services as alternatives to the ED. An evaluation of the CCP interventions for 157 frequent users of the Emergency Department at the University of California, Davis Health System found that patients enrolled in the program for over a year visited the ED fewer times per year than before enrollment; resulting in fewer overnight stays and less total resource cost to the host hospital. Expected savings is estimated to be nearly $9 million per year.
OBJECTIVE: The objective of the study was to test the hypothesis that clinical case management is more cost-effective than usual care for frequent users of the emergency department (ED).
METHODS: The study is a 24-month randomized trial obtaining data on psychosocial problems through interviews and service usage and cost data from administrative records.
RESULTS: Two-hundred fifty-two frequent users were randomized (167 to case management, 85 to usual care). Case management was associated with statistically significant reductions in psychosocial problems common among ED frequent users, including homelessness, alcohol use, lack of health insurance and social security income, and financial need. Case management was associated with statistically significant reductions in ED use and cost. Case management and usual care patients did not differ in use or cost of other hospital services.
CONCLUSIONS: Case management appears cost-effective for ED frequent users because it yields statistically and clinically significant reductions in psychosocial problems at a cost similar to that of usual care.
This study examined the impact of nurse case management interventions on the number of visits of frequent users of a level 1, urban Emergency Department that sees over 70,000 patient visits per year. Frequent users, defined as those having over 3 visits in a month, were tracked before and after implementation of nurse case management interventions designed to reduce their visit rate. It is a 50-patient pilot study and data collection includes whether or not the patient had a primary care provider, the patient's age and gender, insurance status, and the type of case management interventions including medical social work, community referrals, referrals to primary care providers, and limitation of narcotic prescriptions. Based on statistical tests, pre and post case management interventions suggest that case management interventions do not make a statistically significant reduction in the overall number of visits. This is a medically vulnerable patient group whose visits add to the contemporary problem of Emergency Department overcrowding. The ability of case management interventions to reduce the volume of visits and associated impact on reducing Emergency Department overcrowding was not proven.
OBJECTIVE: To evaluate the effects of multidisciplinary case management (CM) on emergency department (ED) utilisation and psychosocial variables for frequent attenders at the ED.
DESIGN: Retrospective cohort analysis, with the study population as historical controls and data analysed 12 months before and after CM intervention in the period 1 January 2000 - 31 December 2004. Subgroup analyses were performed according to primary problem categories: general medical, drug and alcohol, and psychosocial.
SETTING: Inner urban tertiary hospital ED.
PARTICIPANTS: Frequent ED attenders who received CM.
MAIN OUTCOME MEASURES: ED attendances: length of stay, triage category, ambulance transport, disposition, attendances at the only two EDs nearby. Psychosocial factors: housing status, drug and alcohol use, and primary and community care engagement.
RESULTS: 60 CM patients attended the ED on 1387 occasions. Total attendances increased after CM for the whole group (610 v 777, P = 0.055). Mean average length of stay (minutes) of the total study population and each subgroup was unaffected by CM (297 v 300, P = 0.8). Admissions for ED overnight observation increased as a result of CM (P = 0.025). CM increased scores for housing stability (P = 0.007), primary care linkage (P = 0.003), and community care engagement (P < 0.001) for the whole group and variously within subgroups. Drug and alcohol use was unaffected by CM.
CONCLUSION: ED-initiated, multidisciplinary CM appears to increase ED utilisation and have a positive effect on some psychosocial factors for frequent attenders. A trend towards increased ED attendance and utilisation with CM may have implications for policies that seek to divert frequent attenders away from hospitals.
There is a dearth of literature describing the treatment needs of substance-abusing or chronically mentally ill homeless individuals who frequently utilize emergency medical services. This homeless subset represents a discrete population in the larger homeless community. We describe a pilot program, supported by local county public funds, and conducted by a local nonprofit social work agency, which was designed to provide intensive case management services to such a population. Outreach and case management activities resulted in linking clients to a broad range of entitlements and community services. Among those receiving outreach and case management services (n = 10), emergency services decreased by 58% in the year following referral compared to the year before (p <.03). Emergency services for the purpose of this study are defined as ambulance response and transport followed by emergency room admission and treatment. Those in a comparable control group (n = 8) showed no decrease in emergency service use. These results suggest that such community-based outreach programs can significantly improve patient outcome and provide substantial cost savings for local governments and hospitals.
This study examined the impact of case management on hospital service use, hospital costs, homelessness, substance abuse, and psychosocial problems in frequent users of a public urban emergency department (ED). Subjects were 53 patients who used the ED five times or more in 12 months. Utilization, cost, and psychosocial variables were compared 12 months before and after the intervention. The median number of ED visits decreased from 15 to 9 (P < .01), median ED costs decreased from $4,124 to $2,195 (P < .01) and median medical inpatient costs decreased from $8,330 to $2,786 (P < .01). Homelessness decreased by -57% (P < .01), alcohol use by -22% (P = .05) and drug use by -26% (P = .05). Linkage to primary care increased 74% (P < .01). Fifty-four percent of medically indigent subjects obtained Medicaid (P < .01). There was a net cost savings, with each dollar invested in the program yielding a $1.44 reduction in hospital costs. Thus, case management appears to be a cost-effective means of decreasing acute hospital service use and psychosocial problems among frequent ED users.
The authors describe a case-management program for frequent users of the emergency department. The study had a single-subject design, with evaluation for each patient of the number of visits to the emergency department for a 12-month period before referral to the program and a similar period after implementation of an individualized care plan. Referrals were made on the basis of 2 or more of the following criteria: chronic medical condition, complex medical condition, drug-seeking behaviour, violent behaviour and abusive behaviour. A multidisciplinary team developed the individualized care plans. Twenty-four patients agreed to participate. For the 12-month period before their referral, these patients accounted for a total of 616 (median 26.5) visits to the emergency department; for a similar period after implementation of the care plans, they accounted for 175 (median 6.5) visits. The difficult-case management program appeared to be effective in reducing the total number of visits to the emergency department during the study period and in improving the care for these patients.
In 2008, Kern Medical Center established a Care Management Program (CMP) for low-income adults identified as frequent users of hospital services. Frequent users are defined as having 4 or more emergency department (ED) visits or admissions, 3 or more admissions, or 2 or more admissions and 1 ED visit within 1 year. The CMP helps patients access primary care and medical and social resources.
OBJECTIVE:
To determine whether the CMP reduces ED visits and hospitalizations among frequent users.
METHOD:
Between August 2007 and January 2010, a retrospective analysis was conducted using Kern Medical Center encounter data. ED visits and inpatient visits were compared pre- and postenrollment for care managed patients (n = 98). The analysis included a comparison group (n = 160) of frequent users matched on the basis of race and age. Multivariate analyses were performed to evaluate the difference in utilization between groups, and to adjust for potential group differences.
RESULTS:
There was a reduction in the median number of ED visits per year from 6.0 ± 5.0 (median ± interquartile range) pre-enrollment to 1.7 ± 3.3 [corrected] postenrollment (P < 0.0001). The difference in inpatient admissions pre- and postenrollment was 0.0 ± 1.0 (P < 0.0001). After adjusting for multiple factors, multivariate analysis demonstrated that care managed patients had a 32% lower risk of visiting the ED than the comparison group (P < 0.0001). There was no difference in inpatient admissions between groups.
CONCLUSIONS:
CMP that helps patients navigate the health care system and access social and medical resources show significant promise in reducing ED utilization.
