Using emergency department community health workers as a bridge to ongoing care for frequent ED users
Introduction Frequent emergency department (ED) utilizers are common, accounting for about 28–50 percent of all ED visits. Decreasing ED utilization is mentioned as a goal in nearly every healthcare cost reduction initiative. Of particular scrutiny in the medical and lay press have been those patients who use the ED frequently, often referred to as “high utilizers” (≥4 ED visits per year). Patients insured by US public programs (e.g., Medicaid, Medicare, or both) have the highest rates of frequent ED use by far, especially Medicaid patients. One in 12 adult US Medicaid enrollees is a frequent ED utilizer, which, by some estimates, accounts for nearly 50 percent of all ED healthcare costs. As the Affordable Care Act has added millions of new American patients to the Medicaid rosters, this has become appropriately concerning to US policymakers and state officials nationwide. Reducing ED utilization among this group goes far beyond establishing a primary care physician relationship. Detailed studies of Medicaid-enrolled frequent ED users show that the barriers to care are myriad and complex. In fact, 60 percent of Medicaid patients have an established primary care physician yet many suffer from complex chronic diseases, have barriers to accessing timely outpatient services (which include lack of access to transportation, language, cultural, and technological resources), and major social stressors that affect their overall health (e.g., housing and food insecurity). Substance abuse, homelessness, and behavioral health challenges also contribute to frequent ED use, although more notably in the small subset (1–3 percent) of “super users” (≥18 times per year). The trifecta of social, medical, and behavioral stressors creates the perfect storm of access and fuels repeated, potentially avoidable ED use. Intensive, multidisciplinary, community-based care coordination has clearly been shown to decrease ED utilization in addition to achieving cost-effective, patient-centered care for these patients. Several innovative programs provide primary care, health coaching, and behavioral-health home visits for extended periods (usually for 3–6 months, sometimes indefinitely) after patients leave the ED or hospital ward. Patient interviews and evaluations of care coordination programs show that these programs work because they foster long-term relationships with patients – a goal best achieved by community-based care, not directly by ED or hospital staff.
