NYC Health + Hospitals is responsible for more than 1 million emergency department visits annually — roughly one-third of all ED visits throughout the city, with 30% of visits by uninsured patients. Through a Center for Medicare & Medicaid Innovation (CMMI) Award, we tested an interdisciplinary care management model in six of some of the busiest EDs in the country.
NYC Health + Hospitals’ EDs presented untapped opportunities for care management; they leverage a moment when sometimes difficult-to-reach patients are actively seeking care.
Interdisciplinary ED-based care management teams can support increased and successful linkage to primary care services for enrolled patients; however, primary care may be necessary but not sufficient to avert subsequent acute care utilization, at least in the 90-day follow-up window studied.
Challenges to ensure adequate community-based resources to meet patients’ social needs (e.g., unstable housing, poor food access, and unemployment) can limit the impact of transitional care services. These social determinants of health needs may need to be addressed to successfully reduce avoidable ED visits.
NYC Health + Hospitals, the largest municipal health system in the nation, is responsible for more than 1 million emergency department (ED) visits annually — roughly one-third of all ED visits throughout the city, with 30% of visits by uninsured patients. Through a Center for Medicare & Medicaid Innovation (CMMI) Award, we tested an interdisciplinary care management model in six of some of the busiest EDs in the country.
A care management team was embedded in each of the six EDs to meet patients where they seek care and to create appropriate linkages to primary care and community-based services while reducing the need for subsequent acute care utilization. Early analysis indicates that patients who received our care management intervention had greater linkage to primary care services after an initial ED visit than those who did not, but the hospitalization rate and ED revisit rate (within 90 days of the initial ED visit) were not significantly different when compared to a matched control group.
Emergency departments across the country see patients with presenting complaints spanning a broad spectrum of conditions and acuity, from the common cold to sepsis. Of the nearly 141 million ED visits occurring nationally, nearly 10% are for matters that could have been addressed in a lower-cost ambulatory care setting — not in the ED. A contributing factor for why patients seek care in the ED is that they perceive it as a one-stop shop for issues that might otherwise require long waits or multiple primary and specialty care visits. An example of this might be a patient with abdominal pain who visits an internist, gets referred to a gastroenterologist, and ultimately needs several additional appointments for diagnostic- or treatment-related procedures — all to resolve an issue that might have been addressed by a single visit to the ED.
Programs that aim to reduce avoidable high-cost services in favor of a lower-cost setting are challenged by both systemic barriers, including disparate access to primary care and insurance benefit design, and the social circumstances that drive patients’ decisions about when and where to seek care, such as limited ability to take time off work during typical outpatient clinic hours, particularly for multiple visits.
Emergency department care management delivered by an interdisciplinary care team aims to use the ED visit as an opportunity to engage with vulnerable, often hard-to-reach patients who may be socially and economically isolated (e.g., with unstable housing, limited financial resources, and lacking social supports).
Models of ED-based care management have had mixed results in demonstrating effectiveness and often depend on the specifics of care model design, including team composition, caseloads, and duration of intervention, as well as how the target population is defined in terms of risk and complexity. In addition, with multiple care management initiatives often working in parallel, including primary care–based services, embedded psychiatric care, and both hospital-based and telephonic readmission reduction initiatives, it can be difficult to differentiate the impact and outcomes directly associated with each intervention.
The principal aim of our ED care management program was to reduce subsequent acute care utilization after an index ED visit. Additional goals were to successfully embed care management teams within the ED setting, leverage the ED visit as an opportunity to engage otherwise hard-to-reach patients, and increase linkages to primary care and community resources to address ongoing non-emergent care needs longitudinally.
In 2014, we began testing an ED-based care management program by integrating a care team within the ED flow of six of the highest volume EDs in NYC Health + Hospitals. Each ED-based team comprised registered nurse care managers, a community health worker, a pharmacist, a home care nurse, and a physician champion. The physician served primarily as a liaison to practicing colleagues by helping to identify appropriate patients and championing referrals to the program. Each of the community health workers attended an intensive training program aimed at elevating their role of engaging patients and supporting plan of care adherence. The RN care managers worked closely with the pharmacist to provide medication counseling as part of their patient self-management education. Additionally, NYC Health + Hospitals owns a certified home care agency and was able to facilitate direct referrals to home-based services from the ED.
Together, the team engaged and enrolled patients into the program, determined if there were safe alternatives to admission, and ensured that follow-up care was well coordinated. The program successfully enrolled a total of 94,339 patients during the grant period, from September 1, 2014, to August 31, 2017, approximately 60% of eligible patients and 10% of total patients who visited the six EDs.
The intervention comprised several components: face-to-face patient engagement, telephonic follow-up, care planning, medication management, and linkage to community services. Patients eligible for the program included adults treated and discharged from the ED with an Agency for Healthcare Research and Quality (AHRQ)–defined ambulatory care sensitive condition, regardless of insurance status. There were certain other non-emergent conditions, such as patients presenting for medication refills or frequent users of the ED, who were also enrolled.
Prior to discharge, the team initiated a comprehensive needs assessment, completed patient education, and determined clinically appropriate referrals to the patient’s primary care provider (PCP), to home care, or to other community resources. The team strived to connect new patients with the system’s primary care clinics, all of which are NCQA Level 3 Patient-Centered Medical Home (PCMH) certified. After ED discharge, telephonic outreach occurred throughout a 90-day intervention period to ensure that primary care appointments were scheduled and that treatment plans were followed.
While the ED care management team composition and intervention model were consistently deployed across the six facilities, there were differences in how the program functioned within each ED. These differences spanned variation in patient populations, insurance coverage, ED layout and flow, and timely access to a PCP or to community resources. Our socioeconomically and culturally diverse population — including a disproportionate number of patients who are uninsured, transient or homeless, or simply sicker — require discharge plans unique to each patient. Many patients did not have a PCP or were unable to secure access to convenient primary care appointments.
Many enrolled patients also have social needs (e.g., unstable housing, poor food access, unemployment, and lack of transportation) that our intervention and staff were unable to fully address, which further challenged our ability to effectively engage patients in transitional care services and address the underlying factors that may be driving acute care utilization. These social determinants of health are barriers to a successful intervention and require additional strategies for advancing partnerships with community-based organizations.
We have performed analyses using EMR data to begin to gauge the impact of our ED care management model. Program enrollees were compared to a propensity-matched 1:1 control group of patients in the remaining five EDs in the system who could have been enrolled into the ED care management program if it had been present at those sites. The propensity match was based on age, ethnicity, gender, ICD-9 or ICD-10 diagnosis code, payer, and month and year of ED visit.
Key findings include:
- Successful primary care linkage to our PCMH sites within 90 days was on average 15 percentage points greater among enrolled patients compared to the control group. (Successful PCP linkage is defined as a patient having an encounter with a primary care provider and a billable diagnosis code and/or procedure code in our EMR system.) Development of partnerships between the ED and primary care can facilitate access.
- The ED revisit rate within 90 days among enrolled patients declined from 30% in September 2014 to 20% in May 2017. Despite increased PCP linkage, the ED revisit modestly declined and did not significantly differ from the ED revisit rate in the control group, which increased from 26% to 30%. We observed no difference in ED utilization patterns between patients with an assigned PCP and those without.
- No significant difference in inpatient admission rates (within 90 days) was observed among enrolled patients when compared to the control group. The inpatient admission rate remained steady between 4% to 5% for both groups.
Many lessons learned have come from the experience of implementing our ED care management program.
First, successful linkage to a PCP is not sufficient to alter acute care utilization, at least not in the 90-day window measured. While the model demonstrated increased use of primary care among enrolled patients (a goal of our program), early analysis also showed no significant difference in ED utilization patterns between patients with an assigned PCP and those without. Next steps involve applying a longer evaluation period when reviewing the impact of PCP linkage on acute care utilization.
Second, social needs were often uncovered by the ED care management team during patient assessments, but there were limited resources available to address those needs. Although appropriate linkages to primary care and home care occurred, systematic interventions and partnerships to close gaps tied to social determinants of health were not in place to act on the upstream social factors, such as housing instability, influencing patient health and acute service utilization. Leveraging partnerships with community-based organizations and linking patients to social services are important next steps to an enhanced ED care management model.
Third, the scale of the intervention may have diluted the ability to direct resources to the highest-need patients. Although the program was novel in its scale and approach, implementation in six of the busiest NYC EDs with broad patient eligibility criteria may have challenged our ability to effectively target impactful resources for a subset of patients with complex needs. Future efforts involve analyzing patient acuity to inform development of more targeted interventions with “higher-touch” intensity aimed at high-need patients during the follow-up window.
This was a timely initiative for NYC Health + Hospitals to undertake as it also began to develop a system-wide care management strategy tailored to the needs identified in our patient population. State-level initiatives such as New York’s Delivery System Reform Incentive Payment Program also provide funding and permit an opportunity to refine the approach described here. Many of these learnings will inform ongoing work to sustain efforts beyond the award period by integrating into broader care management strategies, including a subsequent iteration of this ED care management program. Additionally, there will be an independent evaluator who will perform a more formal assessment of the results our program.
The project described was supported by Grant Number 1C1CMS331337, “ED Care Management Initiative: Preventing Avoidable ED/Inpatient Use,” from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of NYC Health + Hospitals, the U.S. Department of Health and Human Services, or any of its agencies. The manuscript presented here was written by the awardee. Findings might or might not be consistent with or confirmed by the findings of the independent evaluation contractor.