Care plans for frequent flyers save money, cut costs
Hospital saves more than $500,000
An initiative that creates a care plan that directs frequent users of the emergency department (ED) to more appropriate levels of care has resulted in significant savings for Mercy Medical Center in Canton, OH.
Since the program started in 2001, the average number of visits to the hospital by patients who are part of the program has dropped from 15 a year to an average of three visits a year, according David L. Gormsen, DO, FACEP, chief medical officer and physician advisor to case management.
The hospital anticipates saving $150,000 this year alone in unreimbursed visits and denials for inappropriate admissions, he adds.
At the heart of the program is the hospital’s multidisciplinary ED care management committee, headed by Marilyn Duve, RN, ED case manager.
Members of the committee include the director of the hospital’s drug treatment program, an RN from the hospital’s pain management clinic, a social worker, and a home health nurse, with occasional participation from nurses, physician assistants, or physicians from the ED.
The committee was formed to investigate the ED’s "frequent flyers" and determine why they were frequenting the ED instead of seeking a more appropriate level of care, and to come up with ways to cut down on these patients’ ED use and improve the care they receive.
Their solution was to create an individual care plan for each patient, including medical history and recommendations on what kind of care the patient should receive instead of coming to the ED.
Anyone on the hospital staff can make a referral to the ED case manager for a care plan. Duve welcomes calls from medical staffers who have suggestions for changes in the care plan.
The committee meets once a month and examines patients who have been referred to the program by hospital staff.
The first year, the committee created 21 care plans for frequent users of the ED. There now are 570 ED care plans available to the ED staff and to staff at the hospital’s satellite urgent care centers, according to Susann Stergios, RN, CMC, manager of case management.
A goal for 2006 is to develop a communitywide committee from all hospitals in the city to create care plans that will prevent frequent flyers from hopping from hospital to hospital, says Paula Benson, RN, manager of case management.
"We’ve generated major cost savings because of the fact that people who are on the care plan are no longer coming to the emergency department just to get drugs or because of noncompliance or pain management," Stergios says.
Patients who use the ED frequently include narcotics seekers, people with chronic pain, patients with psychiatric issues who are looking for a kind word or a meal, chronically ill patients who are not compliant with their treatment plan, patients with no income or no medical coverage, and patients who do not have a primary care physician.
"The main focus of our care plans is to make sure that these patients get the best possible care. When they come into the emergency department, they see a different physician every time and nobody follows up with them. Our ED provides wonderful care, but they need a lot more than just emergency care," Duve says.
The care plan includes the patient’s medical history and suggestions for physicians to follow when the patient presents in the ED.
For instance, if a patient appears to be visiting the ED in search of narcotics, the care plan will specify that the patient be given no narcotics and instead be directed to the hospital’s drug treatment program. If the visit is after hours, the physician gives the patient the program’s phone number and encourages him or her to call the next day.
"The hospital anticipates $13 million dollars in charity care write-offs this year. That’s one reason why it’s important that we direct these patients to a more appropriate level of care," Stergios says.
The care plans have improved the satisfaction of ED physicians who are aware that a patient has been a frequent visitor to the ED but don’t have time to follow up.
"Now when someone comes into the emergency department over and over again, the physician can tell them they’re on a care plan and outline what they can do for them," Duve says.
The care plans are only a recommendation from the committee and don’t mean the patients won’t get care — only that they’ll be encouraged to seek care at a more appropriate site in the future, Duve emphasizes.
"It’s never been our intention to stop patients from getting care. Our goal is to see to it that they get the best care they can possibly get. And in the case of a drug seeker, the best possible care means not giving them narcotics," she says.
Many of the "frequent flyers" have psychiatric issues and are in community treatment programs. They come to the ED as many as five or six times a week, often just looking for a kind word, a cup of coffee, or a meal. The counselors, case managers, or social workers are not aware of these emergency department visits until Duve notifies them.
When a patient with a psychiatric issue comes in, Duve contacts the community agency treating him or her and works with the agency to help solve the problem by helping the patient get needed medication, get medications adjusted, or work on becoming compliant with medication regimens.
Some patients come to the emergency department seeking legitimate primary care. "Some people aren’t very trusting of their family physician," Duve says. "They have social issues or their feelings are easily hurt. It’s easier for them to deal with the emergency department physicians, who are in and out of the room quickly."
She sits down with this group of frequent flyers on an individual basis and explains how they’ll get more consistent care if they establish a care relationship with a primary care physician.
"I like to explain to them that the quality of care they’re getting is not the best, that seeing a different emergency department physician once a month isn’t as good as seeing the same family physician who knows their history," she says.
Some of the patients have chronic illnesses but are not taking care of themselves appropriately or aren’t following their treatment plan. In those cases, Duve works with them to help them learn how to be compliant and to cope with their chronic illness. For example, she refers frequent ED patients with congestive heart failure to the hospital’s congestive heart failure coordinator.
Duve is in the ED from noon until 8 p.m. She has been able to place patients in skilled nursing facilities or assisted living facilities directly from the ED, avoiding inappropriate admissions.
"In the past, when I walked into the emergency department, I’d see six or seven people waiting who didn’t need to be there, along with some critically ill people who really required help. Since we started the care plans, I can walk through the emergency department and be assured that all the people who are there need to be there," Duve says.
An initiative that creates a care plan that directs frequent users of the emergency department (ED) to more appropriate levels of care has resulted in significant savings for Mercy Medical Center in Canton, OH.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content. TESTING
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