Every emergency department has experienced the ‘frequent flyer’ phenomenon—cases where patients become repeat visitors because they are chronically ill, seek medical attention, and lack access to other types of care. In a sense, emergency departments were designed to treat a patient’s current condition, not the cause. In the case of America’s frequent fliers, addressing the symptom is the solution to improving long-term health and better outcomes.
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According to a study published in the Annals of Emergency Medicine, frequent fliers represent only 4.5% to 8% of all ED patients, yet account for a disproportionately high percentage of all visits, between 21% and 28%. While the majority of these patients may have serious chronic illnesses like cancer or heart problems that require urgent medical attention, a significant proportion of frequent fliers are made up of individuals with behavioral and social health needs. And for these patients, the ED may not be the appropriate facility for their treatment.
The traditional emergency department is not designed to provide patients with coordinated care. Patients are assessed, treatment is determined and the patient is either admitted to the hospital or cared for and released. While the visit may be noted in the patient’s file, many times there is no follow-up after the visit. Amy Ho, an emergency department physician in Chicago, described this struggle in a particularly eye-opening op-ed. Amy wrote, “With the emergency room so often just the purgatory between drinks for alcoholics, few emergency departments are actually equipped to offer these addicts the help they need beyond their acute intoxication.” Amy and her colleagues are not alone.
For many patients, the ED is their only reliable source of healthcare. They can’t get access to a primary physician, and other clinics are tapped or may be too expensive. In fact, in the second year of the Affordable Care Act, visits to the ED from those covered by Medicaid continued to rise. According to a survey conducted by the American College of Emergency Physicians (ACEP), more than half of physicians surveyed (56 percent) reported the number of Medicaid patient visits is increasing because lack of access to primary care and lack of knowledge of where to seek appropriate care.
Despite the coordination challenge in emergency care, some organizations have improved care and reduced visits from super-utilizers. For example, The Washington State Hospital Association, with input from physicians, established a statewide plan focusing on shared information to improve care management programs and reduce narcotic prescriptions. In Washington, as soon as a person enters an ED, their name is entered into a database and the care team receives information about the patient from all previous in-state ED visits. Medical symptoms, treatment and behavior are documented. Using the data, a care manager can identify patients with social determinents and create a care plan and connect patients with outpatient care if appropriate. As a result of the plan, ED visits decreased by 10 percent, and visits from known super-utilizers dropped 11 percent.
Another success story comes from Aurora Sinai Medical Center, a hospital located in a predominately low-income area of downtown Milwaukee. To reduce costs and connect patients in the ED with primary care, the organization established a program placing full-time social workers in the ED. Through the program, 313 frequent fliers, who alone accounted for 1,827 visits in only four months, were identified. During an eight-month span, the social workers worked exclusively with 39 of the patients to establish a care plan, book follow-up visits and designate primary care physicians. Within the first four months, visits to the ED by the 39 patients dropped 68 percent and the cost of care was reduced by around $1 million. The initial pilot program was a tremendous success and Aurora plans to continue and expand the project.
More providers will need to consider their own strategies on how to reduce frequent fliers in the ED as they aim to improve outcomes and cut costs to deliver value-based care. By connecting patients who have social detriments with truly managed care, we can avoid the constant cycle of ED abuse and better meet the needs of those patients.