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Rolling Out the Red Carpet for ED "Super-Utilizers"? Taking a Patient-Centered Approach

"Super-utilizers"— people who go to the emergency department frequently and often unnecessarily — are often looked down upon, as they constitute a small percent of overall ED patients but account for the majority of costs. Some healthcare providers and the population at large perceive these "super-utilizers" as nuisances — people who make the ED crowded and contribute to long wait times and high costs.

Dr. Alice Petrulis describes a program at MetroHealth to reduce unnecessary ED visits.However, some healthcare organizations are taking a more patient-centered approach to frequent users of the ED. In November, six organizations, including Better Health Greater Cleveland, each received a grant of $200,000 to reduce unnecessary ED visits by coordinating care and improving quality. The Robert Wood Johnson Foundation provided these grants as part of its Aligning Forces for Quality program. Cleveland-based MetroHealth, which is the lead provider organization of Better Health Greater Cleveland, established the Red Carpet Care Program to help patients who visit the ED frequently to access care from the appropriate provider. MetroHealth aims to enroll 150 patients in the voluntary program.

A patient-centered approach

The Red Carpet program takes a patient-centered approach to reducing unnecessary ED visits. This approach recognizes that patients who visit the ED frequently do not purposely drive higher costs at hospitals. "The term 'noncompliant' is used cavalierly," says Alice Stollenwerk Petrulis, MD, medical director of managed care for MetroHealth and clinical champion of the Red Carpet Care program. "They're not being purposely noncompliant; they just don't have the means to manage the system. It's up to us to meet them at their level and help them understand we are there for them."

The term "red carpet" itself is an indication of the new attitude hospitals are taking to frequent ED visitors. "The term was chosen because we want to roll out the red carpet for patients," Dr. Petrulis says. "We want to put patients in the control seat."

Identifying barriers
To involve patients in the initiative to reduce the number of unnecessary ED visits, MetroHealth convened a focus group of 18 patients who visit the ED frequently to determine the reasons for their ED visits. The focus group identified several reasons, including:

•    They can't find a physician who speaks their native language.
•    They can't afford all of their prescriptions.
•    They don't want to go to their primary care physicians if they haven't followed previous orders because they don't want to disappoint the physician.

The patients also described several barriers to seeking care at other sites, such as a physician's office. These barriers included not wanting to be put on hold to make or cancel an appointment; beyond the inconvenience of long holds, many patients don't want to be put on hold for financial reasons because many have phones with limited usage. Despite these barriers, patients want to build a relationship with a primary care physician, according to Dr. Petrulis.

Coordinating care
To address the challenges identified by the focus group, MetroHealth hired two nurse practitioners to function as care coordinators; they will work with two primary care physicians at MetroHealth Medical Center and the family medicine physicians at Broadway Health Center, both in Cleveland.

"The two advanced practice nurses will basically be the lynchpin charged with coordinating the care of the patient," Dr. Petrulis says. Each care coordinator will have a maximum of 75 patients and will not have restricted follow-up time allotments to ensure the care coordinators can spend adequate time with each patient to address his or her individual needs.

The care coordinators will guide patients to the healthcare resources they need and will break down barriers to patients' access to convenient care. One way the care coordinators aim to help frequent ED users access care that is appropriate for their needs is by providing patients in the program who do not have phones with phones that are programmed to call the nurse practitioner directly without being put on hold. In addition, patients will be seen by the same physician and nurse practitioner each time, allowing patients to form a long-term relationship with the physician.

Other ways the care coordinators will help reduce unnecessary ED visits is by organizing van rides for patients who have difficulty finding transportation to medical appointments and by educating patients one-on-one about their medication. Furthermore, if a patient has to go to a specialist, the care coordinator will ensure the specialist and primary care physician know the medication the patient is taking and do not prescribe medications that would adversely interact. "The [care coordinators] will support the patient at a multitude of layers," Dr. Petrulis says.

New financial models
The Red Carpet program will also feature new models of reimbursement. In addition to a fee-for-service schedule, two insurance companies that are working with MetroHealth on the Red Carpet initiative — Medical Mutual of Ohio and Buckeye Health Plan — will pay providers a certain amount each month based on savings from the program. By reducing unnecessary ED visits, the Red Carpet program is expected to save costs; MetroHealth and the insurance companies will share the savings. The insurance companies are also providing funding to support MetroHealth's care coordinators.

More Articles on ED Utilization:

ED "Super-Utilizers" Are Center of Nationwide Initiative
Study: Access to After-Hours Primary Care Predicts ED Use

Crowded EDs Linked to More Patient Deaths, Study Finds

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