Program reduces high ED use, increases primary care visits for most vulnerable patients

Researchers at the University of Colorado Anschutz Medical Campus have found that a community-based program aimed at high users of hospital emergency departments (EDs), reduced ED visits and hospital admissions, while increasing use of primary care providers.

"Many programs have tried to tackle the problem of high utilizers of hospital emergency departments. These are usually people who are on Medicaid," said the study's first author Roberta Capp, MD, an assistant professor of emergency medicine at the University of Colorado School of Medicine. "But this is the first program to show that care coordination actually works."

The study was published October 2, 2017 in the journal Health Affairs.

Capp and her fellow researchers implemented and evaluated Bridges to Care (B2C), an ED-initiated, community-based program. It was one of four sites funded by a Center for Medicare and Medicaid Innovations grant.

The program was led by Rutgers University Center for State Health Policy and developed in collaboration with four Colorado stakeholders including an urban academic hospital, a network of 13 local federally qualified health centers, a mental health clinic and a community advocacy organization.

Researchers compared participants in the B2C program, which focused on Medicaid eligible high ED users, with patients who had received standard care with respect to ED utilization, hospital admission and primary care use.

High ED users were identified as adults who had two or more ED visits or hospital admissions within the last 180 days.

During the six months after B2C enrollment, the participants had 29.7 percent fewer ED visits and 30 percent less hospitalizations. At the same time, they had 123 percent more primary care visits than the control subjects.

"There is a perspective from multiple stakeholders that high users of the ED are difficult patients," Capp said. "But this study shows that patients use the ED because of there are serious barriers to care.

ED care makes up 5 - 6 percent of all healthcare expenses.Previous studies have shown that providing care-coordination services and better access to primary care can reduce waste in healthcare spending. A number of programs addressing low-income, high users of EDs have been implemented with mixed results. Most were hospital-based with little community involvement.

But Capp said the B2C intervention is the first aimed at high users of EDs to combine active outreach in the ED with multidisciplinary, community-based services.It offers intensive medical, behavioral health and social care coordination services. That includes providing a care coordinator, a health coach, a behavioral health specialist, a community health worker and frequent home visits.

Each patient was given a personally tailored, 60-day care plan that included, but was not limited to assistance with getting housing resources, refugee services, access to transportation, help with applying for insurance and disability benefits, setting up primary and specialty care and filling prescriptions.

"We believe that our success stems from bringing together different healthcare systems, breaking down silos between disciplines and focusing on continuity of care in the outpatient setting," Capp said.

The study shows just how intense the services offered to this population must be to reduce their reliance on EDs. One reason is that they often have chronic diseases, including mental illness.

"We learned that active outreach in the ED is key to ensuring successful high utilizer and enrollment and engagement," the study said.

For example, early in the study, the team used call back lists and enrolled only 80 patients in seven to eight months, but when a community health worker was embedded in the ED, enrollment over the same period of time tripled.

"For a program like B2C to be effective, behavioral health services must be provided to high utilizers to ensure comprehensive, multidisciplinary care," Capp said.

She hopes federal lawmakers examining the Affordable Care Act will evaluate the program as a more cost efficient way of providing high quality care to the most vulnerable.