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Two Decades of Rising ED Utilization
“When Americans need healthcare, about half the time they’ll head to the emergency room.” That opening statement from a 2017 article just about sums up the same trend you’ll find from numerous academic studies and articles examining emergency department (ED) utilization over the past twenty years.
The article goes on to examine a University of Maryland study that reviewed data from 1996 to 2010, finding that ED utilization steadily rose over the 14 year period, ultimately contributing an average of 47.7% of hospital-associated medical care in the U.S.
Another study notes that about one-third of ED visits could possibly be handled by a primary care provider (PCP). While socio-economic factors were mixed in that study, several other studies suggest these factors, along with others, can play a role.
In a 2016 study in the Patient Experience Journal, a group of researchers examine why Medicaid patients turn to the ED over a PCP. Providers interviewed in the study noted that both cultural and educational issues impacted the patients’ decisions, including that many Medicaid users had grown up using the ED as their main source of care. The patients themselves noted a “concern that their condition was too serious for the PCP, or that the ED provided more comprehensive services.” Ultimately, while logistical and access concerns needed were also a factor, some level of intervention was needed to address the patients’ perception and understanding of their care options.
Dr. David Marcozzi of the aforementioned University of Maryland study notes in an interview, “‘I believe the surprisingly high proportion of medical care being delivered by emergency departments stems from multiple factors: access to healthcare, consumer-driven needs, an appreciation for the comprehensive care delivered by emergency departments, and the ability of emergency departments to fill a critical gap with regard to care delivered to vulnerable populations.’”
The Cost of Non-Urgent ED Utilization
While the trust patients put in their local EDs is a testament to the compassionate and thorough care delivered by the ED providers, it comes with a downside. As one study notes, “an ED visit is generally not as cost effective as primary care physician visits, and patients do not receive the continuity of care in ED that is provided by primary care physicians with whom an established medical relationship exists.”
But cost and continuity of care are just the beginning. The consistent rise in over utilization is taking a toll. Emergency rooms are consistently becoming overcrowded. Patients often have to be diverted to other hospitals, or experience extended waits for care. Not only does patient care suffer, but emergency physicians feel the toll as well.
Of course, all of these studies were conducted over the past few years – before COVID-19, which put an even greater toll on EDs. There have been plenty of examples of EDs being stretched to their limits during the pandemic, including in New York where a Central Park Field Hospital was established to manage the overflow of COVID-19 patients.
While COVID-19 will eventually be behind us, the challenges faced by EDs long before the pandemic will still be around. In fact, the pandemic has led many healthcare leaders to analyze many of the past and present challenges, and consider strategies that can help address utilization and many other issues facing EDs. In the case of a Colorado ED, many of these challenges have been on the road to improvement for quite some time.
Utilizing Navigators to Help Guide Patients to the Right Care
Back in 2016, the UCHealth University of Colorado Hospital introduced a CareThrough ED Navigator program to optimize utilization and manage population health outcomes. Like many of the other EDs analyzed in the studies mentioned above, they saw uninsured and Medicaid patients consistently utilize the ED for primary care.
At the time, navigator programs were new, and it took time for the providers to trust the navigators to support patients with discharge instructions and connect them to community resources. Furthermore, many patients were visiting outside of normal business – when Medicare or PCP offices were closed – and many didn’t have cell phones for callbacks the next day.
These challenges were eventually solved, and the navigators became a trusted part of the ED team. The site established direct scheduling with local clinics, and relationships were forged with local community resources. The rigorous training program taught navigators how to read body language and other queues to effectively communicate and discern whether patients will show up to their appointments.
Initially, the program aimed to have navigators support appointment scheduling and direct patients to the appropriate PCP care. Since then, the program has evolved to address socio-economic barriers that prevent patients from showing up to their appointments.
The program leadership understands the importance of addressing these barriers. A recent Medical Economics article examines how patient outcomes can be improved when social determinants of health (SDoH) are addressed first. The article notes that physicians cannot solve socio-economic problems alone, and should use additional support to connect patients with community resources. That’s where navigators come in.
Through the ED navigator program, the UCHealth University of Colorado Hospital has seen the needle move in many key indicators, including a 46.3% increase in patients seen per day in a recent 3-month analysis, as navigators have helped give more time back to the care team to spend on direct patient care. Additionally, the ED has seen a reduced 90-day same symptom return rate, reduced acuity symptoms and more.
The navigators routinely help the ED identify patients without insurance, signing them up for Medicaid, or providing education on insurance. They help connect patients to local resources, such as food banks, transportation, housing assistance, child care and more.
Navigators help improve team efficiency, particularly with patient discharge. Often patients may be medically ready but have a social reason they can’t be discharged, such as a ride home or other factors. They’ll help connect patients with the appropriate resources, and provide all other necessary details for the nurses to complete the discharge.
The navigators help provide a variety of key administrative tasks for the care team. The team likes to refer to the navigators as “bootleg social workers,” as they are often at-the-ready with much needed resources. The knowledgeable navigators are able to support SDoH screenings by identifying resources that may help address social barriers.
In a busy ED, providers and social workers are often stretched; it can be difficult to personally identify and address the social barriers that may affect their patients, in addition to delivering patient care. Navigators are invaluable members of the UCHealth University Colorado Hospital ED team. As one team member noted, they make sure patients don’t fall through the cracks; they dig deep to figure out how to reach each patient so they get the follow up they need.