Solutions in the ED: Add-on or value-added?

A few weeks ago, a hospital system that is experienced in failed attempts at reducing non-emergent emergency room visits asked me why people keep coming back to the emergency department (ED). I reflected back on observations over the past eight years and came up with this response:  People keep coming back to the ED because patients tend to be viewed most often in terms of “symptoms and acuity.” 

ED staff are too busy to be good listeners, and as a system, we fail to comprehensively identify the key healthcare motivators and restricting factors that drive an individual’s decision to seek non-emergent care in the ED. EDs are limited in the degree to which they reach outside the ED doors to facilitate patient-centered system integration that connect the dots across health and social service providers and settings, including gains-sharing relationships with community health centers and other safety net providers. Of course, there are EDs around the country successfully managing the issue, but the vast majority still struggle.

I maintain that most hospital leaders agree with this response and are in varying stages of addressing/implementing solutions, but successful implementation of a systems approach to manage ED non-emergent care is expensive and not quickly implemented.  Why? In my opinion, it takes dedicated case management (CM) resources, well designed program infrastructure and outcomes measurement, sufficient operational dollars, and time in program of about two years to demonstrate success. With enormous state and federal healthcare budget cuts and reduced payments to health care providers, this is a difficult sell.  I have seen first year start-up budgets range from $250,000 to $700,000 with upper end costs associated with construction for space allocation and/or information technology requirements.  But, in comparison, what is the cost of doing nothing or implementing a temporary solution? In 2006, in excess of $18 billion dollars was spent for non-emergent care in EDs across the United States.  The spending continues to increase.

Over the last eight years working with health care organizations to address healthcare access and utilization issues, I have observed that ED visit reduction care/case management initiatives that are not appropriately structured and adequately funded provide temporary solutions for a short time only.  These types of initiatives apply an add-on–not value-added–business model, are short-sighted, and often abandoned within a year.  Add-on approaches utilize existing inpatient hospital CM resources by increasing/redesigning workloads to include intermittent staffing assignments to the ED.  This type of model allows missed opportunities for CMs to connect with patients during the ED visit because they are assigned to inpatient units and the ED simultaneously.  When hospitals take a long-term value-added systems approach by investing in dedicated resources, structure, and dollars, they are investing in CM programs that efficiently and effectively connect the dots for individuals by devoting patient-centered time to fully listen and understand where a person is at the moment in relation to their individual perception of health and needs from a bio-psycho-social-environmental impact on health improvements and facilitating access to care and services to meet identified needs via CM input (resources) through to output (outcome).

This approach will not work for every person who frequents the ED, but the successes achieved individually or in aggregate are rewarding, cost effective, and satisfying to hospitals and to those served by them.

Is your facility using long-term or short-term solutions in its emergency department? Which solutions are or aren’t working?