By Nick Zenarosa, M.D., FACEP
Traditionally, population health management has fallen to primary care providers (PCPs), but as more patients opt for the ED instead of a PCP, the responsibility of population health management is shifting.
Becker’s Hospital Review reports that nearly 80 percent of adults ages 18 to 64 visited the ED due to lack of access to other providers. An estimated 56 percent of primary care delivered in EDs is based on preventable, non-urgent visits, according to the Network for Excellence in Health Innovation (NEHI). And, the American College of Emergency Physicians finds that more than 33 percent of all primary care is performed by emergency medicine providers, yet they make up less than 5 percent of the primary care workforce.
An NEHI study identified the following five causes for patient use of the ED for primary care:
- Patients have limited access to timely care services
- The ED provides convenient after-hours and weekend care
- The ED offers patients immediate reassurance about their medical conditions
- Primary care providers refer patients to the ED
- Hospitals have financial and legal obligations to treat all ED patients
The NEHI study further shows that increased insurance coverage under the Affordable Care Act will not drive patients to primary care. Findings indicate that the belief that ED overuse is the result of poor and uninsured seeking non-urgent care may be spurious – these populations were found to be a small subset of the overall population who were using EDs inappropriately. However, the Agency for Healthcare Research & Quality (AHRQ) indicates that if the ED staff encourages patients to an initial primary care visit, they will likely continue to see a PCP.
Disease Management Growing More Difficult, But There’s Hope
Particularly of concern for population health management is the management of chronic disease – especially the growth of Type 2 diabetes mellitus. It can lead to devastating complications such as renal disease, blindness, heart disease, stroke and impaired peripheral circulation. Blood glucose control, particularly decreased glycosylated hemoglobin, is associated with the delay or prevention of these complications. This type of control is achieved by close monitoring of diabetics’ blood glucose results, lifestyle management, diet and medication.
This close monitoring requires consistent, comprehensive care that is best offered in a primary care setting. However, access to primary care may be an issue for these patients.
If the trend of growing ED volumes continues, it could fall on emergency physicians to handle the proliferation of diabetes. Managing the disease requires knowing about it – screening high-risk individuals, actively looking for chronic conditions instead of passively finding out, discharging patients with long-acting insulin, oral hypoglycemic agents and diabetes education to get them started on a treatment plan. If the patient is not stable enough to go home, placement in the observation unit for medication initiation, including insulin and diabetes education, is a reality. He or she can follow up with a PCP, and return to the ED if unable to see PCP within the prescribed time. This approach could be applied to other chronic diseases.
Transitional care clinics, such as acute episodic care clinics, also offer a solution to chronic disease management. These clinics can be open seven days a week for 16 hours or 24 hours with the same triage processes as the ED. Between non-emergent patients and PCP patients looking for urgent care, this approach could save millions of dollars.
Coordinating Care through Established ED Demand Management Techniques
Emergency medicine professionals excel at demand management. Triaging, surge control and vertical flow are all tools that could have wider applications for population health and chronic disease management. ED staffs could improve clinical outcomes by coordinating patient care between the ED and primary care.
Emergency physicians can improve effectiveness and efficiency by coordinating care across the care team:
- Communication with ED providers, ED nurses and others outside of the ED
- ED flow rounds once a shift to ensure everyone on the multidisciplinary team is on the same page
- Ensure successful transitions from the ED and plan for patients’ next steps
- Engage patients as active participants in their care. Without patient and family involvement, the patient is unlikely to be able to manage their disease
A county-owned hospital with a Level-1 trauma center recently implemented some of these population health management techniques in its ED. The results aren’t scientific, just anecdotal, but they are promising:
- A decrease of 28 to 49 hospital bed days per day
- 3 percent decrease in inappropriate inpatient admissions related to diabetes
- $158,000,000 in estimated expenses mitigated annually in aggregate
- Tens of millions of estimated dollars at risk for Medicaid 1115 funding relative to ED process and access to primary care
Moving forward, the ED could use the following proposed metrics to measure success with Type 2 diabetes mellitus patients:
- Number of patients initially diagnosed with Type 2 diabetes mellitus
- Number of patients started on treatment plan
- Number of patients transitioned to primary care clinics
- Number of T2DM patients connected to a clinic who come to the ED for care before and three months after initiation of process
- Decreased number of patients seen for medication refill
In this value-based purchasing environment, it’s more important than ever to keep the frequent ED visitors from doing what they’re used to doing – going straight to the ED when they don’t need emergency care. Getting out in front of population health by tapping the ED to help these “frequent flyers” formulate a more effective care plan could be the key to proactive, preventive care, less ED gridlock and fewer readmissions.
Nick Zenarosa, M.D., FACEP, is President of Integrative Emergency Services, an affiliate of EmCare. He currently serves as the System Medical Director of Emergency Services for Baylor Scott & White North Division. He also is Chairman of Emergency Medicine at John Peter Smith Hospital in Fort Worth, where he oversees the emergency department, the clinical decision unit, urgent care emergency department, and the emergency medicine residency program.
Dr. Zenarosa received his medical degree from the University of Illinois at Chicago College of Medicine. He completed an internal medicine residency at Parkland Memorial Hospital in Dallas and an emergency medicine residency at Carolinas Medical Center in Charlotte, N.C., where he was chief resident.