A patient who comes back to the emergency department repeatedly is often bringing more than a medical problem. Unstable housing, mental health and substance use challenges, food insecurity, unreliable transportation and trouble getting follow-up care can all send individuals back through the ED.
These are needs one ED visit alone cannot meet, and health systems are working to spot them sooner, connecting patients with care in the right setting. Becker’s asked physician leaders at Charlotte, N.C.-based Advocate Health, Oakland, Calif.-based Kaiser Permanente and UChicago Medicine what their systems have done in the past year to address frequent ED visitors. Their approaches depended upon which patients they reach first and how they connect them to help.
Kimberly Stanford, MD, an emergency medicine physician and director of the UChicago Medicine Emergency Department Social Medicine Team, said the team stopped concentrating solely on its heaviest users.
“Rather than focusing exclusively on patients with the highest utilization, who sometimes have up to 20 or more visits in a month, our dedicated ED Social Medicine Team now reviews patients with four or more ED visits in a month to identify unmet needs and opportunities for intervention,” Dr. Stanford said.
Lowering the threshold changed which problems the team sees. “We’ve found that our highest utilizers often face complex challenges related to housing, mental health, and substance use that are difficult to address through ED-based interventions alone,” Dr. Stanford said. “By broadening our focus, we’ve identified patients with more immediately actionable needs, such as inadequate home services or transportation challenges, and have begun connecting them with appropriate support.”
Those patients were easy to miss. Their visit counts looked modest next to the highest utilizers, and Dr. Stanford said “the pattern of repeated visits might not be apparent to clinicians during an individual ED encounter.” She added: “Yet many of their needs can be addressed through existing patient navigation and social work resources.”
The results so far are a lesson in setting priorities in addressing patient needs. “While we don’t yet have data demonstrating reductions in ED visits, this shift in focus has reinforced an important lesson: the patients with the most ED visits aren’t necessarily those whose needs we are best equipped to address,” Dr. Stanford said.
Kaiser Permanente is addressing similar underlying needs, but across millions of members. Anand Shah, MD, senior vice president for community and social health at the system, framed the problem from his own time in the ED.
“As an emergency physician, I learned early that when someone comes back to the emergency department again and again, the reason is often not just medical,” Dr. Shah said. “The visit in front of you may be only part of the story.”
The system’s most important step, he said, has been identifying those needs more consistently and connecting people with help. The push started with a member survey several years ago: More than 60% of respondents reported at least one social need in the past year.
“That was a wake-up call. Even though our members are insured, many still face barriers that affect their health and how they use care,” Dr. Shah said.
This year, Kaiser Permanente expects to screen more than 4 million members through mobile outreach, pre-visit questionnaires and conversations at the point of care, with results feeding into the EHR. It expects to offer support to about 1.5 million of them.
The Community Support Hub anchors the work. It connects members and nonmembers with community resources for food security, housing and transportation. “For care teams, it helps move the work from simply identifying a need to making a referral, checking whether services were received, and following up when more support is needed,” Dr. Shah said.
Kaiser Permanente has also added community health workers for members with the most complex needs. The model began in the system’s Northwest region, which includes the Portland, Ore., metro area. In randomized controlled trials, it returned $427 per member per month, largely through fewer hospitalizations and hospital days. The system has since deployed it in the ED.
Dr. Shah was candid about the limits. “We know this does not solve every barrier patients face. But by identifying social needs, connecting people with community resources, and following through to see whether those connections are made, we are addressing many of the underlying factors that contribute to repeat emergency department visits and poorer health outcomes,” he said.
Where Kaiser Permanente screens broadly, Advocate Health starts with the individual patient. “The most important step Advocate Health has taken to address frequent ED visitors has been identifying the clinical needs and potential barriers to accessing care for those patients,” said David Trotter, MD, executive medical director of emergency medicine for the system’s Illinois and Wisconsin divisions.
A tailored, coordinated treatment plan follows. Advocate also studies ED use patterns, which Dr. Trotter said helps the system separate two groups: “We are better positioned to distinguish between the patients who need immediate acute care and those who may benefit from a multidisciplinary outpatient care approach.”
To give continued support to the second group, Advocate is strengthening its virtual care, community-based services and access to primary and behavioral healthcare. “Moving forward, we will continue to evaluate the impact of these efforts through ED data, successful connection to outpatient resources and overall patient outcomes,” Dr. Trotter said.
Across the three systems, the common thread is a shift in where leaders look for need. For Dr. Stanford, the heaviest users still need more than one hospital can give, but patients one tier down are within reach today.
“While improving care for our highest utilizers will require greater investment in infrastructure, resources, and support outside the hospital system, broadening our approach to patients with moderately frequent ED visits has created opportunities to intervene earlier and address unmet social needs using resources we already have,” she said.
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