Emergency Department Patient Navigator Program Demonstrates Reduction in Emergency Department Return Visits and Increase in Follow-up Appointment Adherence

Development and Psychometric Analysis of a Patient-Reported Measure of Diagnostic Excellence for Emergency and Urgent Care Settings

BACKGROUND

Emergency and urgent care settings face challenges with routinely obtaining performance feedback related to diagnostic care. Patients and their care partners provide an important perspective on the diagnostic process and outcome of care in these settings. We sought to develop and test psychometric properties of Patient-Report to IMprove Diagnostic Excellence in Emergency Department settings (PRIME-ED), a measure of patient-reported diagnostic excellence in these care settings.

METHODS

We developed PRIME-ED based on literature review, expert feedback, and cognitive testing. To assess psychometric properties, we surveyed AmeriSpeak, a probability-based panel that provides sample coverage of approximately 97% of the U.S. household population, in February 2022 to adult patients, or their care partners, who had presented to an emergency department or urgent care facility within the last 30 days. Respondents rated their agreement on a 5-point Likert scale with each of 17 statements across multiple domains of patient-reported diagnostic excellence. Demographics, visit characteristics, and a subset of the Emergency Department Consumer Assessment of Healthcare Providers & Systems were also collected. We conducted psychometric testing for reliability and validity.

RESULTS

Over a thousand (n = 1116) national panelists completed the PRIME-ED survey, of which 58.7% were patients and 40.9% were care partners; 49.6% received care at an emergency department and 49.9% at an urgent care facility. Responses had high internal consistency within 3 patient-reported diagnostic excellence domain groupings: diagnostic process (Cronbach's alpha 0.94), accuracy of diagnosis (0.93), and communication of diagnosis (0.94). Domain groupings were significantly correlated with concurrent Emergency Department Consumer Assessment of Healthcare Providers & Systems items. Factor analyses substantiated 3 domain groupings.

CONCLUSIONS

PRIME-ED has potential as a tool for capturing patient-reported diagnostic excellence in emergency and urgent care.

Patient engagement in the development and implementation of navigation services: a scoping review protocol

INTRODUCTION

Patient navigation, a complex health intervention meant to address widespread fragmentation across the healthcare landscape, has been widely adopted internationally. This rapid uptake in patient navigation has led to a broadening of the service's reach to include those of different social positions and different health conditions. Despite the popularity and prevalence of patient navigation programmes, the extent of patient involvement and/or partnership in their construction has yet to be articulated. This scoping review will explore and describe the extent to which patients have been engaged in the development and/or implementation of patient navigation programmes to date.

METHODS AND ANALYSIS

This scoping review will adhere to the Arksey and O'Malley framework for conducting scoping reviews. The electronic databases MEDLINE, CINAHL, EMBASE, PsycINFO, SocINDEX and Scopus were searched in September 2023 using terms related to patient navigation and programme implementation. Inclusion criteria stipulate that the studies must: (1) include an intervention labelled as 'navigation' in a healthcare setting and (2) describe patient engagement in the design, development and/or implementation process of said patient navigation programme. To assess study eligibility, two reviewers will independently read through the titles and abstracts, followed by the full texts, of each study identified from the search strategy to determine whether they meet inclusion criteria. Reviewers will then extract data from the included studies, present descriptive study characteristics in tables, and perform qualitative content analysis.

ETHICS AND DISSEMINATION

This review does not require ethics approval as data will be collated exclusively from peer-reviewed articles and thesis dissertations. A manuscript summarising the results of the review will be written and submitted to a peer-reviewed journal for publication. The review will map aspects of programme development that have repeatedly utilised patient perspectives and areas where engagement has lagged. This review will also depict how patient engagement varies across programme characteristics.

Characteristics of patients who return unplanned to the ED, and factors that contribute to their decision to return: Integrated results from an explanatory sequential mixed methods inquiry

AIM

To identify common characteristics of patients who return to the ED unplanned and factors that may contribute to their decision to return.

BACKGROUND

Return visits to the Emergency Department (ED) have been associated with adverse events and deficits in initial care provided. There is increasing evidence to suggest that many return visits may be preventable.

METHODS

The results of primary quantitative measures (QUAN) followed by qualitative measures (qual) were integrated to build on and explain the quantitative data found in the initial phase of the research.

RESULTS

Integration of results produced three new findings. 1) Most return visits occurred beyond 48 hrs because patients intentionally delayed going back to the ED despite their persisting symptoms; 2) Clinical urgency and deterioration were rarely evident in patients who made return visits in patients and 3) Ineffective communication between the clinician and the patient at discharge may have contributed to patients making the decision to return to the ED.

CONCLUSION

The decision to return unplanned to the ED is not an immediate response for most patients, and several potentially avoidable factors may influence their decision-making process. Future research should focus on strategies which contribute to the avoidance of unplanned return visits.

Emergency Department-to-Community Transitions of Care: Best Practices for the Older Adult Population

This article describes emergency department (ED)-to-community care transitions for older adults and associated challenges, measurement, proven efficacious and effective interventions, and policy considerations. Older adults experiencing social isolation and impairments in functional status or cognition represent unique populations that are particularly at risk during ED-to-community transitions of care and may benefit from targeted intervention implementation. Future efforts should target optimizing screening techniques to identify those at risk, developing and validating patient-centered outcome measures, and using policy and reimbursement levers to include transitional care management services for older adults within the ED setting.

Social Determinants of Health Screening and Management: Lessons at a Large, Urban Academic Health System

BACKGROUND

In October 2022 a multisite social determinants of health screening initiative was expanded across seven emergency departments of a large, urban hospital system. The aim of the initiative was to identify and address those underlying social needs that frequently interfere with a patient's health and well-being, often resulting in increased preventable system utilization.

METHODS

Building on an established Patient Navigator Program, an existing screening process, and long-standing community-based partnerships, an interdisciplinary workgroup was formed to develop and implement the initiative. Technical and operational workflows were developed and implemented, and new staff members were hired and trained to screen and support patients with identified social needs. In addition, a community-based organization network was formed to explore and test social service referral strategies.

RESULTS

Within the first five months of implementation, more than 8,000 patients were screened across seven emergency departments (EDs), of which 17.3% demonstrated a social need. Patient Navigators see between 5% and 10% of total nonadmitted ED patients. Among the three social needs of focus, housing presented as the greatest need (10.2%), followed by food (9.6%) and transportation (8.0%). Among patients identified as rising/high risk (728), 50.0% accepted support and are actively working with a Patient Navigator.

CONCLUSION

There is growing evidence to support the link between unmet social needs and poor health outcomes. Health care systems are uniquely positioned to provide whole person care by identifying unresolved social needs and by building capacity within local community-based organizations to support those needs.

Novel Discharge Center for Transition of Care in Vulnerable Emergency Department Treat and Release Patients

Introduction The majority of emergency department (ED) patients are discharged following evaluation and treatment. Most patients are recommended to follow up with a primary care provider (PCP) or specialist. However, there is considerable variation between providers and EDs in discharge process practices that might facilitate such follow-up (e.g., simply discharging patients with follow-up physician names/contact information vs. making appointments for patients). Patients who do not follow up with their PCPs or specialists are more likely to be readmitted within 30 days than those who do. Furthermore, vulnerable patients have difficulty arranging transitional care appointments due to poor health literacy, inadequate insurance, appointment availability, and self-efficacy. Our innovative ED discharge process utilizes an Emergency Department Discharge Center (EDDC) staffed by ED Care Coordinators and assists patients with scheduling post-discharge appointments to improve rates of follow-up with outpatient providers. This study describes the structure and activities of the EDDC, characterizes the EDDC patient population, and demonstrates the volume and specialties of appointments scheduled by EDDC Care Coordinators. The impact of the EDDC on operational metrics (72-hour returns, 30-day admissions, and length-of-stay [LOS]) and the impact of the EDDC on patient satisfaction are evaluated. Methods The Long Island Jewish Medical Center (LIJMC) EDDC is an intervention developed in July 2020 within a 583-bed urban hospital serving a racially, ethnically, and socio-economically diverse population, with many patients having limited access to healthcare. Data from the Emergency Medicine Service Line (EMSL), an ED Care Coordinator database, and manual chart review were collected from July 2020 to July 2021 to examine the impact of the EDDC on 72-hour returns, 30-day admissions, and Press Ganey's® "likelihood to recommend ED" score (a widely used patient satisfaction survey question). The EDDC pilot cohort was compared to non-EDDC discharged patients during the same period. Results In unadjusted analysis, EDDC patients were moderately less likely to return to the ED within 72 hours (5.3% vs. 6.5%; p = 0.0044) or be admitted within 30 days (3.4% vs. 4.2%). The program was particularly beneficial for uninsured and elderly patients. For both EDDC and non-EDDC patients, most revisits and 30-day admissions were for the same chief complaint as the index visit. The length-of-stay increased by ~10 minutes with no impact on satisfaction with ED visits. Musculoskeletal conditions (~20%) and specialties (~15%) were the most commonly represented. Approximately 10% of referrals were to obtain a PCP. Nearly 90% were to new providers or specialties. Most scheduled appointments occurred within a week.  Conclusion This novel EDDC program, developed to facilitate outpatient follow-up for discharged ED patients, produced a modest but statistically significant difference in 72-hour returns and 30-day admissions for patients with EDDC-scheduled appointments vs. those referred to outpatient providers using the standard discharge process. ED LOS increased by ~10 minutes for EDDC vs. non-EDDC patients, with no difference in satisfaction. Future analyses will investigate impacts on 72-hour returns, 30-day admissions, LOS, and satisfaction after adjusting for characteristics such as age, insurance, having a PCP, and whether the scheduled appointment was attended.

Comparison of emergency pediatric breast ultrasound interpretations and management recommendations between pediatric radiologists and breast imaging radiologists

PURPOSE

Pediatric patients with breast-related symptoms often initially present to the emergency department for evaluation. While pediatric radiologists are accustomed to evaluating acute infectious and traumatic etiologies, they may be less familiar with breast-specific findings. This study compares management recommendations of pediatric breast ultrasounds performed in the emergency setting between pediatric and breast imaging radiologists.

METHODS

This retrospective cohort study reviewed data from all pediatric breast ultrasounds performed in the emergency setting from a single academic institution from 1/1/14 to 12/31/19. During the study period, 12 pediatric radiologists with experience ranging from 1 to 33 years interpreted pediatric breast ultrasounds. Three breast imaging radiologists (with 3, 8, and 25 years of experience) retrospectively reviewed each case and recorded whether further management was recommended. Differences in recommendations were compared using Fisher's exact test. Cohen's kappa was used to assess agreement between subspecialty radiologists.

RESULTS

This study included 75 pediatric patients, with mean age 13 ± 5.6 years and malignancy rate of 1.3% (1/75). Pediatric radiologists and the most experienced breast imaging radiologist had moderate agreement in management recommendations (k = 0.54). There was no significant difference in recommendations for further management between pediatric radiologists (22/75 [29.3%]) and the most experienced breast imaging radiologist (15/75 [20.0%]), p = 0.26.

CONCLUSION

Recommendations for pediatric breast complaints in the emergency setting are comparable between subspecialties.