A Pattern, Not a Prognosis: Identifying and addressing the underlying causes behind high ED utilization in patients

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It’s impossible to understand how to evaluate and treat a patient without understanding the life context they bring to a clinical scenario.

Two patients presenting with the same complaint can need two completely different evaluations and treatments depending on their life’s context. 

Where did they come from? What is their previous disposition to disease based on genetics? Based on social situation? How does substance use, poverty, homelessness, or food fragility play a role? 

Each outside issue creates the context that helps physicians and care teams understand a patient they’re addressing for the first time. And yet, for many ED physicians, we walk into first encounters with patients “flying blind” and without any context to help determine what conversations need to be had and treatments that need to take place. 

The Dangers in Labeling Patients as “High Utilizers” 

When we treat patients without knowing their background—including social determinants of health—it’s easy to make quick assumptions that will impact or even jade the care we give an individual. For patients with patterns of high utilization, this is especially true. 

Tracking patients who return to the ED over and over again—whether that’s to the same hospital, to collections of nearby hospitals, or up and down the western coast—it becomes easy to write off a patient as just being “a high utilizer” and blame a chronic condition for these visits. 

When care teams dig deeper into these patients and their surrounding circumstances, it quickly becomes clear that the utilization is a symptom of another problem—not the problem itself. It is not about the asthma, the sickle cell, the congestive heart failure, or the diabetes. Rarely is high utilization solely because of a disease.

High utilization is a pattern signifying an underlying problem that is preventing the chronic care condition from being handled at a lower and more appropriate acuity level. If we are too quick to label, dismiss, and move on, we miss the opportunity to discover what really is the problem and will likely end up seeing the patient again. 

Improving Care by Looking Past Primary Complaints

Once we’re able to look past a patient’s initial complaint and accept that there might be other factors at play, it gets easier to see where other problems might be hiding. 

Imagine those hidden picture games that are in the children’s magazines at doctor offices. You look at the page and see a park scene, but you also soon realize the hidden objects are in unexpected places. The soccer ball is in a bike tire, a crayon is the armrest of a park bench, the bell is actually the old man’s hat. But once we know to look for these “hidden” items, they’re actually easy to spot—even if it’s not the main thing we’re told to see. 

When patients present, it’s easy to just look at that primary complaint as the big picture—choosing not to look for other contributors to the patient’s health. Layering on additional evaluations that proactively screen for mental health needs, homelessness, substance use disorder, prescription drug misuse, and other issues can make not-so-hidden problems become obvious and give clues as to what additional resources these patients may need.  

We can do better at implementing processes that involve a list of things to potentially screen for—aside from the primary complaint—that may provide valuable context to highlight what we as physicians should be doing to better care for each patient as a whole.  

Looking Beyond Symptoms for Solutions

With the fast-paced nature of emergency medicine, it is easy to argue that it’s simply not possible to screen for all these things and still meet with all our patients. But being able to quickly identify context—even for patients you’re seeing for the first time—is a critical component for practicing medicine in the ED.

Utilizing tools that automatically flag potential issues upfront can help prioritize provider workflows—striking a balance between personalized patient care and care team workload. 

Technology that quickly identifies whether the patient has access to healthcare (especially primary care), taps into prescription drug databases, or alerts care teams of comorbid mental health diagnoses can help eliminate some of the guesswork in knowing where to look for additional factors contributing to a patient’s health. When these platforms also facilitate care collaboration, like the Collective Medical platform does, it can make connecting these patients to the right healthcare and community resources that much easier. 

For example, we often have children present with asthma exacerbation. The technology alerts me that the child has a listed primary care clinic, which means today’s episode should have been preventable. This context allows me to approach the bedside armed with what I need to be able to have a conversation with the patient and the parents to discover what needs to be changed.

From informed and honest conversations like these, we’re able to gain valuable insights into the core issue. The steroid inhaler might be too expensive, or with the parent’s working schedule it could be difficult to get the child into the pediatrician during regular working hours. There may be other factors in play, like torn families, homelessness, or food insecurity. 

Once we know what the real issue is, we can take steps to address the issues behind the utilization—coordinating with insurance to negotiate out of pocket costs for the inhaler, connecting with a primary care clinic that better accommodates working schedules, or working with community shelters and setting the patient up with food stamps—and ultimately improve the quality of care and overall patient outcomes. 

Related Reading: Standing Up for Individuals with Intellectual Developmental Disabilities

Dr. Jason Greenspan, MD is an Emergency Medicine physician and Associate Chief Medical Officer, practicing with Emergent Medical Associates (EMA) since graduating as Chief Resident in Emergency Medicine at LA County/USC hospital in 2002. His current responsibilities include direct patient care, the direction and management of over one hundred physicians and mid-level practitioners, as well as direct interaction with all levels of hospital administration and management. Dr. Greenspan has also served as the Director of Telemedicine and Regional Medical Director for EMA, developing and implementing tele-health solutions in EMA’s Emergency Departments. 

Jamie Eng, MD graduated from Chicago Medical School in 2009 and completed her Emergency Medicine residency at LAC+USC Medical Center in 2013. She has worked as an Emergency Medicine physician at Providence Tarzana Medical Center, CA since 2013 and as an attending physician at LAC+USC. She is currently the Associate ED Director of Providence Tarzana.

This article is a collaborative effort with Collective Medical

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