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Kelekar U, Das Gupta D, Theis-Mahon N, Fashingbauer E, Huang B. Distances to emergency departments and non-urgent utilization of medical services: a systematic review. Glob Health Action 2024; 17:2353994. [PMID: 38828477 PMCID: PMC11149577 DOI: 10.1080/16549716.2024.2353994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/08/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND The use of Emergency Departments (EDs) for non-urgent medical conditions is a global public health concern. OBJECTIVES A systematic review, guided by a registered protocol (PROSPERO: CRD42023398674), was conducted to interpret the association between distance as a measure of healthcare access and the utilization of EDs for non-urgent care in high- and middle-income countries. METHODS The search was conducted on 22 August 2023 across five databases using controlled vocabulary and natural language keywords. Eligibility criteria included studies that examined non-urgent care, and featured concepts of emergency departments, non-urgent health services and distance, reported in English. Articles and abstracts where patients were transported by ambulance/paramedic services, referred/transferred from another hospital to an ED, or those that measured distance to an ED from another health facility were excluded. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework informed the quality of evidence. RESULTS Fifteen articles met the inclusion criteria. All studies demonstrated satisfactory quality with regard to study design, conduct, analysis and presentation of results. Eight (53.3%) of the studies (1 paediatric, 4 all ages/adult, 3 ecological) found a moderate level of evidence of an inverse association between distance and ED visit volume or utilization for non-urgent medical conditions, while the remaining studies reported very low or low evidence. CONCLUSIONS Half of the studies reported non-urgent ED use to be associated with shortest distance traveled or transportation time. This finding bears implications for healthcare policies aiming to reduce ED use for non-urgent care.
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Affiliation(s)
- Uma Kelekar
- Innovation, Leadership and Technology/Center for Optimal Aging, Marymount University College of Business, Arlington, VA, USA
| | - Debasree Das Gupta
- Kinesiology and Health Science Department, Utah State University Emma Eccles Jones College of Education and Human Services, Logan, UT, USA
| | | | - Emily Fashingbauer
- Minnesota State University College of Allied Health and Nursing, Mankato, MN, USA
| | - Boyen Huang
- University of Minnesota School of Dentistry, Minneapolis, MN, USA
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Hudon C, Chouinard MC, Doucet S, Piccinini-Vallis H, Fairman K, Sampalli T, Zed J, Brodeur M, Chênevert D, Dépelteau A, Dupont M, Karam M, Légaré F, Luke A, Macdonald M, Morvannou A, Ramsden VR, Rodriguez Del Barrio L, Wong ST, Lambert M, Bisson M, Schwarz C, Benoit R, Poirier MD, Rock-Hervieux AL, Rubenstein D, Wilhelm L. Case management in primary healthcare for people with complex needs to improve integrated care: a large-scale implementation study protocol. BMJ Open 2024; 14:e083783. [PMID: 39134438 PMCID: PMC11331999 DOI: 10.1136/bmjopen-2023-083783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 07/15/2024] [Indexed: 08/21/2024] Open
Abstract
INTRODUCTION Case management (CM) is among the most studied effective models of integrated care for people with complex needs. The goal of this study is to scale up and assess CM in primary healthcare for people with complex needs. METHODS AND ANALYSIS The research questions are: (1) which mechanisms contribute to the successful scale-up of CM for people with complex needs in primary healthcare?; (2) how do contextual factors within primary healthcare organisations contribute to these mechanisms? and (3) what are the relationships between the actors, contextual factors, mechanisms and outcomes when scaling-up CM for people with complex needs in primary healthcare? We will conduct a mixed methods Canadian interprovincial project in Quebec, New-Brunswick and Nova Scotia. It will include a scale-up phase and an evaluation phase. At inception, a scale-up committee will be formed in each province to oversee the scale-up phase. We will assess scale-up using a realist evaluation guided by the RAMESES checklist to develop an initial programme theory on CM scale-up. Then we will test and refine the programme theory using a mixed-methods multiple case study with 10 cases, each case being the scalable unit of the intervention in a region. Each primary care clinic within the case will recruit 30 adult patients with complex needs who frequently use healthcare services. Qualitative data will be used to identify contexts, mechanisms and certain outcomes for developing context-mechanism-outcome configurations. Quantitative data will be used to describe patient characteristics and measure scale-up outcomes. ETHICS AND DISSEMINATION Ethics approval was obtained. Engaging researchers, decision-makers, clinicians and patient partners on the study Steering Committee will foster knowledge mobilisation and impact. The dissemination plan will be developed with the Steering Committee with messages and dissemination methods targeted for each audience.
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Affiliation(s)
- Catherine Hudon
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | | | - Shelley Doucet
- Department of Nursing and Health Sciences, University of New Brunswick, Saint John, New Brunswick, Canada
| | | | - Kimberly Fairman
- Institute for Circumpolar Health Research, Yellowknife, Northwest Territories, Canada
| | - Tara Sampalli
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Joanna Zed
- Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Magaly Brodeur
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Denis Chênevert
- Department of Human Resources Management, HEC Montreal, Montreal, Quebec, Canada
| | - Andréa Dépelteau
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Mariève Dupont
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Marlène Karam
- Faculty of Nursing, Université de Montréal, Montreal, Quebec, Canada
| | - France Légaré
- Faculty of Medicine, Universite Laval, Quebec, Quebec, Canada
| | - Alison Luke
- Department of Nursing and Health Sciences, University of New Brunswick, Saint John, New Brunswick, Canada
| | - Marilyn Macdonald
- School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Adele Morvannou
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, Universite de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Vivian R Ramsden
- Department of Academic Family Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Sabrina T Wong
- Centre for Health Services and Policy Research and School of Nursing, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Mireille Lambert
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Mathieu Bisson
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Charlotte Schwarz
- Department of Nursing and Health Sciences, University of New Brunswick, Saint John, New Brunswick, Canada
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Angrignon-Girouard É, Schwarz C, Howse D, Aubrey K, Bisson M, Chouinard MC, Dickinson L, Doucet S, Dubois MF, Dumont-Samson O, Hudon C. The CONECT-6 case-finding tool to identify patients with complex needs: A few tips to promote understanding. J Eval Clin Pract 2024. [PMID: 39129340 DOI: 10.1111/jep.14129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 07/21/2024] [Indexed: 08/13/2024]
Affiliation(s)
- Émilie Angrignon-Girouard
- Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Charlotte Schwarz
- Faculty of Nursing and Health Sciences, University of New Brunswick, Fredericton, New Brunswick, Canada
| | - Dana Howse
- Faculty of Medicine, Memorial University, St. John's, Newfoundland and Labrador, Canada
| | - Kris Aubrey
- Faculty of Medicine, Memorial University, St. John's, Newfoundland and Labrador, Canada
| | - Mathieu Bisson
- Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | | | - Laura Dickinson
- Faculty of Nursing and Health Sciences, University of New Brunswick, Fredericton, New Brunswick, Canada
| | - Shelley Doucet
- Faculty of Nursing and Health Sciences, University of New Brunswick, Fredericton, New Brunswick, Canada
| | - Marie-France Dubois
- Department of Community Health Sciences, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Olivier Dumont-Samson
- Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Catherine Hudon
- Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Sherbrooke, Quebec, Canada
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Nummedal MA, King S, Uleberg O, Pedersen SA, Bjørnsen LP. Non-emergency department (ED) interventions to reduce ED utilization: a scoping review. BMC Emerg Med 2024; 24:117. [PMID: 38997631 PMCID: PMC11242019 DOI: 10.1186/s12873-024-01028-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 06/20/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Emergency department (ED) crowding is a global burden. Interventions to reduce ED utilization have been widely discussed in the literature, but previous reviews have mainly focused on specific interventions or patient groups within the EDs. The purpose of this scoping review was to identify, summarize, and categorize the various types of non-ED-based interventions designed to reduce unnecessary visits to EDs. METHODS This scoping review followed the JBI Manual for Evidence Synthesis and the PRISMA-SCR checklist. A comprehensive structured literature search was performed in the databases MEDLINE and Embase from 2008 to March 2024. The inclusion criteria covered studies reporting on interventions outside the ED that aimed to reduce ED visits. Two reviewers independently screened the records and categorized the included articles by intervention type, location, and population. RESULTS Among the 15,324 screened records, we included 210 studies, comprising 183 intervention studies and 27 systematic reviews. In the primary studies, care coordination/case management or other care programs were the most commonly examined out of 15 different intervention categories. The majority of interventions took place in clinics or medical centers, in patients' homes, followed by hospitals and primary care settings - and targeted patients with specific medical conditions. CONCLUSION A large number of studies have been published investigating interventions to mitigate the influx of patients to EDs. Many of these targeted patients with specific medical conditions, frequent users and high-risk patients. Further research is needed to address other high prevalent groups in the ED - including older adults and mental health patients (who are ill but may not need the ED). There is also room for further research on new interventions to reduce ED utilization in low-acuity patients and in the general patient population.
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Affiliation(s)
- Målfrid A Nummedal
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
| | - Sarah King
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Oddvar Uleberg
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Sindre A Pedersen
- The Medicine and Health Library, Library Section for Research Support, Data and Analysis, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Lars Petter Bjørnsen
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
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Samosh J, Agha A, Pettey D, Sylvestre J, Aubry T. Community Mental Health Services for Frequent Emergency Department Users: A Qualitative Study of Outcomes Perceived by Program Clients and Case Managers. Prof Case Manag 2024; 29:139-148. [PMID: 38037223 DOI: 10.1097/ncm.0000000000000692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
PURPOSE OF STUDY This study aimed to investigate the perceived outcomes and mechanisms of change of a community mental health service combining system navigation and intensive case management supports for frequent emergency department users presenting with mental illness or addiction. PRIMARY PRACTICE SETTING The study setting was a community mental health agency receiving automated referrals directly from hospitals in a midsize Canadian city for all individuals attending an emergency department two or more times within 30 days for mental illness or addiction. METHODOLOGY AND SAMPLE Qualitative interviews with 15 program clients. Focus groups with six program case managers. Data were analyzed using pragmatic qualitative thematic analysis. RESULTS Participants generally reported perceiving that the program contributed to reduced emergency department use, reduced mental illness symptom severity, and improved quality of life. Perceived outcomes were more mixed for outcomes related to addiction. Reported mechanisms of change emphasized the importance of positive working relationships between program clients and case managers, as well as focused efforts to develop practical skills. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE Community mental health services including intensive case management for frequent emergency department users presenting with mental illness or addiction were perceived to effectively address client needs while reducing emergency department resource burden. Similar programs should emphasize the development of consistent and warm working relationships between program clients and case managers, as well as practical skills development to support client health and well-being.
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Affiliation(s)
- Jonathan Samosh
- Jonathan Samosh, MSc, is a PhD candidate in Clinical Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. His research interests include community mental health and homelessness
- Ayda Agha, MScCH, is a PhD candidate in Experimental Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. Her research interests include community mental health and homelessness
- Donna Pettey, PhD, RSW, is Director of Integration, Research, and Evaluation at the Canadian Mental Health Association's Ottawa Branch. She provides research leadership to the agency to support clinical decision-making in the provision of community mental health services
- John Sylvestre, PhD, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
- Tim Aubry, PhD, CPsych, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
| | - Ayda Agha
- Jonathan Samosh, MSc, is a PhD candidate in Clinical Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. His research interests include community mental health and homelessness
- Ayda Agha, MScCH, is a PhD candidate in Experimental Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. Her research interests include community mental health and homelessness
- Donna Pettey, PhD, RSW, is Director of Integration, Research, and Evaluation at the Canadian Mental Health Association's Ottawa Branch. She provides research leadership to the agency to support clinical decision-making in the provision of community mental health services
- John Sylvestre, PhD, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
- Tim Aubry, PhD, CPsych, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
| | - Donna Pettey
- Jonathan Samosh, MSc, is a PhD candidate in Clinical Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. His research interests include community mental health and homelessness
- Ayda Agha, MScCH, is a PhD candidate in Experimental Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. Her research interests include community mental health and homelessness
- Donna Pettey, PhD, RSW, is Director of Integration, Research, and Evaluation at the Canadian Mental Health Association's Ottawa Branch. She provides research leadership to the agency to support clinical decision-making in the provision of community mental health services
- John Sylvestre, PhD, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
- Tim Aubry, PhD, CPsych, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
| | - John Sylvestre
- Jonathan Samosh, MSc, is a PhD candidate in Clinical Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. His research interests include community mental health and homelessness
- Ayda Agha, MScCH, is a PhD candidate in Experimental Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. Her research interests include community mental health and homelessness
- Donna Pettey, PhD, RSW, is Director of Integration, Research, and Evaluation at the Canadian Mental Health Association's Ottawa Branch. She provides research leadership to the agency to support clinical decision-making in the provision of community mental health services
- John Sylvestre, PhD, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
- Tim Aubry, PhD, CPsych, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
| | - Tim Aubry
- Jonathan Samosh, MSc, is a PhD candidate in Clinical Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. His research interests include community mental health and homelessness
- Ayda Agha, MScCH, is a PhD candidate in Experimental Psychology at the University of Ottawa's School of Psychology and Centre for Research on Educational and Community Services. Her research interests include community mental health and homelessness
- Donna Pettey, PhD, RSW, is Director of Integration, Research, and Evaluation at the Canadian Mental Health Association's Ottawa Branch. She provides research leadership to the agency to support clinical decision-making in the provision of community mental health services
- John Sylvestre, PhD, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
- Tim Aubry, PhD, CPsych, is Full Professor at the School of Psychology and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. His research interests include community mental health and homelessness
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Moon F, Knott J, Feely S. Examining management plans for patients who frequently presented to the emergency department. Australas Emerg Care 2024; 27:114-118. [PMID: 37923610 DOI: 10.1016/j.auec.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/11/2023] [Accepted: 10/11/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Patients who frequently present to Emergency Department (ED) experience complex health and social needs. While research has examined interventions that aim to decrease frequent ED attendances, there is a need to understand the types of interventions provided to patients by hospital clinicians during presentations. METHODS Using qualitative content analysis, 82 management plans were evaluated to understand the scope and type of interventions provided by clinicians for patients frequently presenting to the ED at the Royal Melbourne Hospital, Australia. RESULTS Patients often presented to the ED due to mental and psychological distress, substance use and physical health concerns alongside psychosocial vulnerabilities. The goals of care documented in plans focussed on management of health issues, aggression within the ED, and coordinating care with community services. Recommended interventions addressed presenting needs with multi-disciplinary approach to respond to distress and aggression. Finally, the plans provided insight into service coordination dynamics between the ED and community-based health and social care services. CONCLUSIONS The plans recommended interventions that sought to provide holistic care for patients in collaboration with relevant community-based services. The findings suggest that clinicians in the ED can provide appropriate and meaningful care for patients who experience frequent presentations.
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Affiliation(s)
- Felicity Moon
- Emergency Department, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC 3050, Australia.
| | - Jonathan Knott
- Emergency Department, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC 3050, Australia; Department of Critical Care, University of Melbourne, Grattan Street, Parkville, VIC 3050, Australia
| | - Siobhan Feely
- Emergency Department, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC 3050, Australia
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Rotily M, Persico N, Lamouroux A, Rojas-Vergara AC, Loundou A, Boucekine M, Apostolidis T, Odena S, Chischportich C, Auquier P. Health mediation does not reduce the readmission rate of frequent users of emergency departments living in precarious conditions: what lessons can be learned from this randomised controlled trial? BMC Emerg Med 2024; 24:83. [PMID: 38750416 PMCID: PMC11094847 DOI: 10.1186/s12873-024-01000-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 05/06/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Severe overcrowding of emergency departments (EDs) affects the quality of healthcare. One factor of overcrowding is precariousness, but it has rarely been considered a key factor in designing interventions to improve ED care. Health mediation (HM) aims to facilitate access to rights, prevention, and care for the most vulnerable persons and to raise awareness among healthcare providers about obstacles in accessing healthcare. The primary aim was to determine whether HM intervention for frequent users of EDs (FUED) living in precarious conditions could reduce the readmission rate at 90 days. METHODS Between February 2019 and May 2022, we enrolled and interviewed 726 FUED in four EDs of southeastern France in this randomised controlled trial. The HM intervention started in the ED and lasted 90 days. In addition to the primary endpoint (first readmission at 90 days), secondary endpoints (readmission at 30 and 180 days, number of hospitalisations at 30, 90, 180 days, admissions for the same reasons as the first admission) were also studied. The outcomes were measured in the ED information systems. Statistical methods included an intention-to-treat analysis and a per-protocol analysis. Comparisons were adjusted for gender, age, ED, and health mediator. RESULTS 46% of patients reported attending the ED because they felt their life was in danger, and 42% had been referred to the ED by the emergency medical dispatch centre or their GP; 40% of patients were considered to be in a serious condition by ED physicians. The proportion of patients who were readmitted at 90 days was high but did not differ between the control and the HM intervention groups (31.7% vs. 36.3%, p = 0.23). There was no significant difference in any of the secondary outcome measures between the control and HM intervention groups. Per-protocol analysis also showed no significant difference for the primary and secondary endpoints. CONCLUSIONS This randomised controlled trial did not show that our health mediation intervention was effective in reducing the use of emergency services by FUED living in precarious conditions. Some limitations are discussed: the duration of the intervention (90 days), the long-term effects (> 6 months), the involvement of the ED staff. TRIAL REGISTRATION Registered on clinicaltrials.gov as NCT03660215 on 4th September 2018.
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Affiliation(s)
- Michel Rotily
- Centre d'Etudes et de Recherche sur les services de santé et la qualité de vie (CEReSS), Aix Marseille Université, Marseille, France.
| | - Nicolas Persico
- Service des Urgences, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Aurore Lamouroux
- Centre de santé hospitalo-universitaire des Aygalades, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Ana Cristina Rojas-Vergara
- Centre de santé hospitalo-universitaire des Aygalades, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Anderson Loundou
- Centre d'Etudes et de Recherche sur les services de santé et la qualité de vie (CEReSS), Aix Marseille Université, Marseille, France
| | - Mohamed Boucekine
- Centre d'Etudes et de Recherche sur les services de santé et la qualité de vie (CEReSS), Aix Marseille Université, Marseille, France
| | - Themistoklis Apostolidis
- Laboratoire de Psychologie Sociale (LPS), Aix Marseille Université, Aix en Provence, Marseille, France
| | - Sophie Odena
- Laboratoire d'Economie et de Sociologie du Travail, Aix Marseille Université, Centre National de la Recherche Scientifique, Aix en Provence, Marseille, France
| | | | - Pascal Auquier
- Centre d'Etudes et de Recherche sur les services de santé et la qualité de vie (CEReSS), Aix Marseille Université, Marseille, France
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Gallagher D, Bentley B, Barry A, Fraccola A, Santos R, Glenn A, Howard J, Kamath A, Flanagan K. Development of an Emergency Department Case Management Case-Finding Tool. Prof Case Manag 2024; 29:102-110. [PMID: 37982739 PMCID: PMC10984631 DOI: 10.1097/ncm.0000000000000699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
PURPOSE OF STUDY Identifying emergency department (ED) patients who are at high risk for return visits is an important goal for case management to improve patient care. This quality improvement study describes the development and evaluation of the Emergency Department Case Management Priority Score (EDCMPS), an electronic medical record (EMR)-based "case-finding" system, and its ability to identify these high-risk patients. In addition, the authors present data about its acceptability among emergency department case managers (ED CMs). PRIMARY PRACTICE SETTINGS Emergency departments with case management availability and staffing. METHODOLOGY AND SAMPLE A retrospective analysis at Duke University Hospital ED compared patient data pre- and postimplementation of the EDCMPS. The tool was developed using the LEAN and Plan-Do-Study-Act (PDSA) quality improvement methodologies, with ED CM participation. ED return and hospitalization rates within 7 and 30 days between both methods were compared, and a survey evaluated CM satisfaction with the EDCMPS. RESULTS The 2-month preintervention period (July 1, 2022, to August 31, 2022) included 8,677 patients discharged from the ED, with 897 patients (10.3%) identified as at high risk for return based on the previous manual methodology. In the 3-month postintervention period (September 1, 2022, to November 30, 2022), there were 13,566 patients discharged, with 692 patients (5.1%) identified as at high risk for return using the EDCMPS. The EDCMPS outperformed the manual method, yielding a significantly higher odds ratio (OR) for 7- and 30-day ED return or hospitalization (e.g., 30-day any return OR = 4.21 vs. 1.69). The survey showed broad ED CM agreement on the tool's superior performance, especially in organizing outpatient resources and referring to support programs. However, challenges in securing primary care follow-up, housing, and health insurance applications were identified. The tool's collaborative development approach ensured its fit to ED CM needs, contributing to its success. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE The EDCMPS showcases promise in enhancing ED CM efficiency, with strong frontline staff endorsement. It pinpoints areas needing focus for patient support and has the potential to reduce ED revisits and therefore health care utilization. Its methodology offers insights for similar future implementations in health care institutions.
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Affiliation(s)
- David Gallagher
- Address correspondence to David Gallagher, MD, SFHM, Duke University School of Medicine, DUMC Box 3508, Durham, NC 27710 ()
| | - Barbara Bentley
- David Gallagher, MD, SFHM, is the Chief Medical Officer for Duke University Hospital and previously was Chief of Hospital Medicine programs. He is Associate Professor of Medicine at Duke University and has published in a variety of hospital-based quality improvement areas. He also works clinically as a hospitalist
- Barbara Bentley, MBA, MSN, RN, CCM, is the Assistant Director of Case Management at Duke University Hospital. She has numerous roles within case management including leadership over Duke Hospital Emergency Department Case Management. She has 20+ years of experience in case management in a variety of settings and responsibilities
- Ashley Barry, MSN, MMCi, RN, is Application Analyst at Duke University Health Technology Solutions. She is a registered nurse with advanced training in medical informatics. She has much experience in clinical project management, quality improvement, and patient safety
- Amy Fraccola, MSN, RN, ACM, is the Director of Case Management at Duke Raleigh Hospital. She has many years of case management leadership experience and before joining Duke she worked at Penn Highlands Healthcare
- Rosimeire Santos, MS, is Data Analytics Engineer with Duke Health and has significant experience in data analysis involving Epic and Cerner Information Systems as well as project management experience at multiple academic medical centers
- Adam Glenn, BSIE, LSSBB, is an Improvement Engineer with Duke University Health System. Adam has expertise in project management, quality improvement, LEAN and Six Sigma methodologies, and change management. He serves as a leader for strategic health system priorities focused on improving quality of care as well as experience for patients and staff
- James Howard, MD, is the Duke Hospital Medicine Nocturnist Associate Medical Director and Assistant Professor of Medicine at Duke School of Medicine. He works clinically as a hospitalist. He has expertise in clinical quality and safety, patient experience, and physician leadership
- Aparna Kamath, MD, is Duke Raleigh Hospital's Medical Director for Quality and works extensively in quality initiatives including mortality, length of stay, and readmissions reduction projects. She is Associate Professor of Medicine at Duke University and has a master's degree in Clinical Investigation
- Katie Flanagan, MSW, LCSW, ACM-SW, is the Assistant Vice President for Care Coordination for Duke University Health System. She has significant training and experience in case management and leadership. She is the current President of the North Carolina Chapter of the American Case Management Association
| | - Ashley Barry
- David Gallagher, MD, SFHM, is the Chief Medical Officer for Duke University Hospital and previously was Chief of Hospital Medicine programs. He is Associate Professor of Medicine at Duke University and has published in a variety of hospital-based quality improvement areas. He also works clinically as a hospitalist
- Barbara Bentley, MBA, MSN, RN, CCM, is the Assistant Director of Case Management at Duke University Hospital. She has numerous roles within case management including leadership over Duke Hospital Emergency Department Case Management. She has 20+ years of experience in case management in a variety of settings and responsibilities
- Ashley Barry, MSN, MMCi, RN, is Application Analyst at Duke University Health Technology Solutions. She is a registered nurse with advanced training in medical informatics. She has much experience in clinical project management, quality improvement, and patient safety
- Amy Fraccola, MSN, RN, ACM, is the Director of Case Management at Duke Raleigh Hospital. She has many years of case management leadership experience and before joining Duke she worked at Penn Highlands Healthcare
- Rosimeire Santos, MS, is Data Analytics Engineer with Duke Health and has significant experience in data analysis involving Epic and Cerner Information Systems as well as project management experience at multiple academic medical centers
- Adam Glenn, BSIE, LSSBB, is an Improvement Engineer with Duke University Health System. Adam has expertise in project management, quality improvement, LEAN and Six Sigma methodologies, and change management. He serves as a leader for strategic health system priorities focused on improving quality of care as well as experience for patients and staff
- James Howard, MD, is the Duke Hospital Medicine Nocturnist Associate Medical Director and Assistant Professor of Medicine at Duke School of Medicine. He works clinically as a hospitalist. He has expertise in clinical quality and safety, patient experience, and physician leadership
- Aparna Kamath, MD, is Duke Raleigh Hospital's Medical Director for Quality and works extensively in quality initiatives including mortality, length of stay, and readmissions reduction projects. She is Associate Professor of Medicine at Duke University and has a master's degree in Clinical Investigation
- Katie Flanagan, MSW, LCSW, ACM-SW, is the Assistant Vice President for Care Coordination for Duke University Health System. She has significant training and experience in case management and leadership. She is the current President of the North Carolina Chapter of the American Case Management Association
| | - Amy Fraccola
- David Gallagher, MD, SFHM, is the Chief Medical Officer for Duke University Hospital and previously was Chief of Hospital Medicine programs. He is Associate Professor of Medicine at Duke University and has published in a variety of hospital-based quality improvement areas. He also works clinically as a hospitalist
- Barbara Bentley, MBA, MSN, RN, CCM, is the Assistant Director of Case Management at Duke University Hospital. She has numerous roles within case management including leadership over Duke Hospital Emergency Department Case Management. She has 20+ years of experience in case management in a variety of settings and responsibilities
- Ashley Barry, MSN, MMCi, RN, is Application Analyst at Duke University Health Technology Solutions. She is a registered nurse with advanced training in medical informatics. She has much experience in clinical project management, quality improvement, and patient safety
- Amy Fraccola, MSN, RN, ACM, is the Director of Case Management at Duke Raleigh Hospital. She has many years of case management leadership experience and before joining Duke she worked at Penn Highlands Healthcare
- Rosimeire Santos, MS, is Data Analytics Engineer with Duke Health and has significant experience in data analysis involving Epic and Cerner Information Systems as well as project management experience at multiple academic medical centers
- Adam Glenn, BSIE, LSSBB, is an Improvement Engineer with Duke University Health System. Adam has expertise in project management, quality improvement, LEAN and Six Sigma methodologies, and change management. He serves as a leader for strategic health system priorities focused on improving quality of care as well as experience for patients and staff
- James Howard, MD, is the Duke Hospital Medicine Nocturnist Associate Medical Director and Assistant Professor of Medicine at Duke School of Medicine. He works clinically as a hospitalist. He has expertise in clinical quality and safety, patient experience, and physician leadership
- Aparna Kamath, MD, is Duke Raleigh Hospital's Medical Director for Quality and works extensively in quality initiatives including mortality, length of stay, and readmissions reduction projects. She is Associate Professor of Medicine at Duke University and has a master's degree in Clinical Investigation
- Katie Flanagan, MSW, LCSW, ACM-SW, is the Assistant Vice President for Care Coordination for Duke University Health System. She has significant training and experience in case management and leadership. She is the current President of the North Carolina Chapter of the American Case Management Association
| | - Rosimeire Santos
- David Gallagher, MD, SFHM, is the Chief Medical Officer for Duke University Hospital and previously was Chief of Hospital Medicine programs. He is Associate Professor of Medicine at Duke University and has published in a variety of hospital-based quality improvement areas. He also works clinically as a hospitalist
- Barbara Bentley, MBA, MSN, RN, CCM, is the Assistant Director of Case Management at Duke University Hospital. She has numerous roles within case management including leadership over Duke Hospital Emergency Department Case Management. She has 20+ years of experience in case management in a variety of settings and responsibilities
- Ashley Barry, MSN, MMCi, RN, is Application Analyst at Duke University Health Technology Solutions. She is a registered nurse with advanced training in medical informatics. She has much experience in clinical project management, quality improvement, and patient safety
- Amy Fraccola, MSN, RN, ACM, is the Director of Case Management at Duke Raleigh Hospital. She has many years of case management leadership experience and before joining Duke she worked at Penn Highlands Healthcare
- Rosimeire Santos, MS, is Data Analytics Engineer with Duke Health and has significant experience in data analysis involving Epic and Cerner Information Systems as well as project management experience at multiple academic medical centers
- Adam Glenn, BSIE, LSSBB, is an Improvement Engineer with Duke University Health System. Adam has expertise in project management, quality improvement, LEAN and Six Sigma methodologies, and change management. He serves as a leader for strategic health system priorities focused on improving quality of care as well as experience for patients and staff
- James Howard, MD, is the Duke Hospital Medicine Nocturnist Associate Medical Director and Assistant Professor of Medicine at Duke School of Medicine. He works clinically as a hospitalist. He has expertise in clinical quality and safety, patient experience, and physician leadership
- Aparna Kamath, MD, is Duke Raleigh Hospital's Medical Director for Quality and works extensively in quality initiatives including mortality, length of stay, and readmissions reduction projects. She is Associate Professor of Medicine at Duke University and has a master's degree in Clinical Investigation
- Katie Flanagan, MSW, LCSW, ACM-SW, is the Assistant Vice President for Care Coordination for Duke University Health System. She has significant training and experience in case management and leadership. She is the current President of the North Carolina Chapter of the American Case Management Association
| | - Adam Glenn
- David Gallagher, MD, SFHM, is the Chief Medical Officer for Duke University Hospital and previously was Chief of Hospital Medicine programs. He is Associate Professor of Medicine at Duke University and has published in a variety of hospital-based quality improvement areas. He also works clinically as a hospitalist
- Barbara Bentley, MBA, MSN, RN, CCM, is the Assistant Director of Case Management at Duke University Hospital. She has numerous roles within case management including leadership over Duke Hospital Emergency Department Case Management. She has 20+ years of experience in case management in a variety of settings and responsibilities
- Ashley Barry, MSN, MMCi, RN, is Application Analyst at Duke University Health Technology Solutions. She is a registered nurse with advanced training in medical informatics. She has much experience in clinical project management, quality improvement, and patient safety
- Amy Fraccola, MSN, RN, ACM, is the Director of Case Management at Duke Raleigh Hospital. She has many years of case management leadership experience and before joining Duke she worked at Penn Highlands Healthcare
- Rosimeire Santos, MS, is Data Analytics Engineer with Duke Health and has significant experience in data analysis involving Epic and Cerner Information Systems as well as project management experience at multiple academic medical centers
- Adam Glenn, BSIE, LSSBB, is an Improvement Engineer with Duke University Health System. Adam has expertise in project management, quality improvement, LEAN and Six Sigma methodologies, and change management. He serves as a leader for strategic health system priorities focused on improving quality of care as well as experience for patients and staff
- James Howard, MD, is the Duke Hospital Medicine Nocturnist Associate Medical Director and Assistant Professor of Medicine at Duke School of Medicine. He works clinically as a hospitalist. He has expertise in clinical quality and safety, patient experience, and physician leadership
- Aparna Kamath, MD, is Duke Raleigh Hospital's Medical Director for Quality and works extensively in quality initiatives including mortality, length of stay, and readmissions reduction projects. She is Associate Professor of Medicine at Duke University and has a master's degree in Clinical Investigation
- Katie Flanagan, MSW, LCSW, ACM-SW, is the Assistant Vice President for Care Coordination for Duke University Health System. She has significant training and experience in case management and leadership. She is the current President of the North Carolina Chapter of the American Case Management Association
| | - James Howard
- David Gallagher, MD, SFHM, is the Chief Medical Officer for Duke University Hospital and previously was Chief of Hospital Medicine programs. He is Associate Professor of Medicine at Duke University and has published in a variety of hospital-based quality improvement areas. He also works clinically as a hospitalist
- Barbara Bentley, MBA, MSN, RN, CCM, is the Assistant Director of Case Management at Duke University Hospital. She has numerous roles within case management including leadership over Duke Hospital Emergency Department Case Management. She has 20+ years of experience in case management in a variety of settings and responsibilities
- Ashley Barry, MSN, MMCi, RN, is Application Analyst at Duke University Health Technology Solutions. She is a registered nurse with advanced training in medical informatics. She has much experience in clinical project management, quality improvement, and patient safety
- Amy Fraccola, MSN, RN, ACM, is the Director of Case Management at Duke Raleigh Hospital. She has many years of case management leadership experience and before joining Duke she worked at Penn Highlands Healthcare
- Rosimeire Santos, MS, is Data Analytics Engineer with Duke Health and has significant experience in data analysis involving Epic and Cerner Information Systems as well as project management experience at multiple academic medical centers
- Adam Glenn, BSIE, LSSBB, is an Improvement Engineer with Duke University Health System. Adam has expertise in project management, quality improvement, LEAN and Six Sigma methodologies, and change management. He serves as a leader for strategic health system priorities focused on improving quality of care as well as experience for patients and staff
- James Howard, MD, is the Duke Hospital Medicine Nocturnist Associate Medical Director and Assistant Professor of Medicine at Duke School of Medicine. He works clinically as a hospitalist. He has expertise in clinical quality and safety, patient experience, and physician leadership
- Aparna Kamath, MD, is Duke Raleigh Hospital's Medical Director for Quality and works extensively in quality initiatives including mortality, length of stay, and readmissions reduction projects. She is Associate Professor of Medicine at Duke University and has a master's degree in Clinical Investigation
- Katie Flanagan, MSW, LCSW, ACM-SW, is the Assistant Vice President for Care Coordination for Duke University Health System. She has significant training and experience in case management and leadership. She is the current President of the North Carolina Chapter of the American Case Management Association
| | - Aparna Kamath
- David Gallagher, MD, SFHM, is the Chief Medical Officer for Duke University Hospital and previously was Chief of Hospital Medicine programs. He is Associate Professor of Medicine at Duke University and has published in a variety of hospital-based quality improvement areas. He also works clinically as a hospitalist
- Barbara Bentley, MBA, MSN, RN, CCM, is the Assistant Director of Case Management at Duke University Hospital. She has numerous roles within case management including leadership over Duke Hospital Emergency Department Case Management. She has 20+ years of experience in case management in a variety of settings and responsibilities
- Ashley Barry, MSN, MMCi, RN, is Application Analyst at Duke University Health Technology Solutions. She is a registered nurse with advanced training in medical informatics. She has much experience in clinical project management, quality improvement, and patient safety
- Amy Fraccola, MSN, RN, ACM, is the Director of Case Management at Duke Raleigh Hospital. She has many years of case management leadership experience and before joining Duke she worked at Penn Highlands Healthcare
- Rosimeire Santos, MS, is Data Analytics Engineer with Duke Health and has significant experience in data analysis involving Epic and Cerner Information Systems as well as project management experience at multiple academic medical centers
- Adam Glenn, BSIE, LSSBB, is an Improvement Engineer with Duke University Health System. Adam has expertise in project management, quality improvement, LEAN and Six Sigma methodologies, and change management. He serves as a leader for strategic health system priorities focused on improving quality of care as well as experience for patients and staff
- James Howard, MD, is the Duke Hospital Medicine Nocturnist Associate Medical Director and Assistant Professor of Medicine at Duke School of Medicine. He works clinically as a hospitalist. He has expertise in clinical quality and safety, patient experience, and physician leadership
- Aparna Kamath, MD, is Duke Raleigh Hospital's Medical Director for Quality and works extensively in quality initiatives including mortality, length of stay, and readmissions reduction projects. She is Associate Professor of Medicine at Duke University and has a master's degree in Clinical Investigation
- Katie Flanagan, MSW, LCSW, ACM-SW, is the Assistant Vice President for Care Coordination for Duke University Health System. She has significant training and experience in case management and leadership. She is the current President of the North Carolina Chapter of the American Case Management Association
| | - Katie Flanagan
- David Gallagher, MD, SFHM, is the Chief Medical Officer for Duke University Hospital and previously was Chief of Hospital Medicine programs. He is Associate Professor of Medicine at Duke University and has published in a variety of hospital-based quality improvement areas. He also works clinically as a hospitalist
- Barbara Bentley, MBA, MSN, RN, CCM, is the Assistant Director of Case Management at Duke University Hospital. She has numerous roles within case management including leadership over Duke Hospital Emergency Department Case Management. She has 20+ years of experience in case management in a variety of settings and responsibilities
- Ashley Barry, MSN, MMCi, RN, is Application Analyst at Duke University Health Technology Solutions. She is a registered nurse with advanced training in medical informatics. She has much experience in clinical project management, quality improvement, and patient safety
- Amy Fraccola, MSN, RN, ACM, is the Director of Case Management at Duke Raleigh Hospital. She has many years of case management leadership experience and before joining Duke she worked at Penn Highlands Healthcare
- Rosimeire Santos, MS, is Data Analytics Engineer with Duke Health and has significant experience in data analysis involving Epic and Cerner Information Systems as well as project management experience at multiple academic medical centers
- Adam Glenn, BSIE, LSSBB, is an Improvement Engineer with Duke University Health System. Adam has expertise in project management, quality improvement, LEAN and Six Sigma methodologies, and change management. He serves as a leader for strategic health system priorities focused on improving quality of care as well as experience for patients and staff
- James Howard, MD, is the Duke Hospital Medicine Nocturnist Associate Medical Director and Assistant Professor of Medicine at Duke School of Medicine. He works clinically as a hospitalist. He has expertise in clinical quality and safety, patient experience, and physician leadership
- Aparna Kamath, MD, is Duke Raleigh Hospital's Medical Director for Quality and works extensively in quality initiatives including mortality, length of stay, and readmissions reduction projects. She is Associate Professor of Medicine at Duke University and has a master's degree in Clinical Investigation
- Katie Flanagan, MSW, LCSW, ACM-SW, is the Assistant Vice President for Care Coordination for Duke University Health System. She has significant training and experience in case management and leadership. She is the current President of the North Carolina Chapter of the American Case Management Association
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Giannouchos TV, Ukert B, Pirrallo RG, Smith J, Kum HC, Wright B, Dietrich A. Determinants of Persistent, Multi-Year, Frequent Emergency Department Use Among Children and Young Adults in Three US States. Acad Pediatr 2024; 24:442-450. [PMID: 37673206 DOI: 10.1016/j.acap.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 07/11/2023] [Accepted: 08/28/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVE This study examines the factors associated with persistent, multi-year, and frequent emergency department (ED) use among children and young adults. METHODS We conducted a retrospective secondary analysis using the 2012-2017 Healthcare Cost and Utilization Project State Emergency Department Databases for children and young adults aged 0-19 who visited any ED in Florida, Massachusetts, and New York. We estimated the association between persistent frequent ED use and individuals' characteristics using multivariable logistic regression models. RESULTS Among 1.3 million patients with 1.8 million ED visits in 2012, 2.9% (37,558) exhibited frequent ED use (≥4 visits in 2012) and accounted for 10.2% (181,138) of all ED visits. Longitudinal follow-up of frequent ED users indicated that 15.4% (5770) remained frequent users periodically over the next 1 or 2 years, while 2.2% (831) exhibited persistent frequent use over the next 3-5 years. Over the 6-year study period, persistent frequent users had 31,551 ED visits at an average of 38.0 (standard deviation = 16.2) visits. Persistent frequent ED use was associated with higher intensity of ED use in 2012, public health insurance coverage, inconsistent health insurance coverage over time, residence in non-metropolitan and lower-income areas, multimorbidity, and more ED visits for less medically urgent conditions. CONCLUSIONS Clinicians and policymakers should consider the diverse characteristics and needs of pediatric persistent frequent ED users compared to broader definitions of frequent users when designing and implementing interventions to improve health outcomes and contain ED visit costs.
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Affiliation(s)
- Theodoros V Giannouchos
- Department of Health Policy & Organization (TV Giannouchos), School of Public Health, The University of Alabama at Birmingham, Birmingham, Ala.
| | - Benjamin Ukert
- Department of Health Policy and Management (B Ukert, H-C Kum), School of Public Health, Texas A and M University, College Station, Tex
| | - Ronald G Pirrallo
- University of South Carolina School of Medicine (RG Pirrallo, J Smith, and A Dietrich), Greenville, SC; Department of Emergency Medicine (RG Pirrallo, J Smith, and A Dietrich), Prisma Health, Greenville, SC
| | - Jeremiah Smith
- University of South Carolina School of Medicine (RG Pirrallo, J Smith, and A Dietrich), Greenville, SC; Department of Emergency Medicine (RG Pirrallo, J Smith, and A Dietrich), Prisma Health, Greenville, SC
| | - Hye-Chung Kum
- Department of Health Policy and Management (B Ukert, H-C Kum), School of Public Health, Texas A and M University, College Station, Tex
| | - Brad Wright
- Department of Health Services Policy and Management (B Wright), Arnold School of Public Health, University of South Carolina, Columbia, SC
| | - Ann Dietrich
- University of South Carolina School of Medicine (RG Pirrallo, J Smith, and A Dietrich), Greenville, SC; Department of Emergency Medicine (RG Pirrallo, J Smith, and A Dietrich), Prisma Health, Greenville, SC
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10
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Rasmussen MK, Benthien KS, Nielsen CP, Rasmussen K, Grønkjær M, Toft U, Kidholm K. Cost-effectiveness of proactive health support-telephone-based self-management support compared with standard care for persons at risk of hospital admission. Age Ageing 2024; 53:afae036. [PMID: 38476101 DOI: 10.1093/ageing/afae036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND A small share of patients account for a large proportion of costs to the healthcare system in Denmark as in many Western countries. A telephone-based self-management support, proactive health support (PaHS), was suggested for prevention of hospitalisations for persons at risk of hospital admission. These persons have chronic diseases, unplanned hospitalisations and age ≥ 65 years. However, evidence is limited on whether this type of intervention is cost-effective. AIM The aim of this study was to assess the incremental cost-utility ratio (ICER) of PaHS, compared with standard care. METHODS The economic evaluation was nested within a randomised controlled trial, and was based on a health system perspective, with follow-up and time horizon of 12 months. We measured incremental costs per quality-adjusted life years (QALY) gained. Total average costs per patient included PaHS programme costs, and costs in hospitals, primary care and municipalities. We analysed differences by generalised linear models with Gamma distribution for costs and mixed models for QALY. RESULTS We analysed data on 6,139 patients, where 3,041 received PaHS and 3,098 received usual care. We found no difference in healthcare costs, and programme costs were on average €1,762 per patient, providing incremental costs of €2,075. Incremental effects on QALY were 0.007, resulting in an ICER of €296,389 per QALY gained. CONCLUSION We found no evidence of PaHS being cost-effective in this study, but the results will be used to identify new ways to organise similar interventions and identify patients with the objective to reduce health system costs per patient.
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Affiliation(s)
- Maja Kjær Rasmussen
- Centre for Innovative Medical Technology, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Kirstine Skov Benthien
- Centre for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
- Palliative Care Unit, Copenhagen University Hospital, Hvidovre, Denmark
| | - Camilla Palmhøj Nielsen
- DEFACTUM-Social & Health Services and Labour Market, Aarhus, Denmark
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Knud Rasmussen
- Department of Data and Development Support, Region Zealand, Sorø, Denmark
| | - Mette Grønkjær
- Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark
| | - Ulla Toft
- Centre for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Kristian Kidholm
- Centre for Innovative Medical Technology, Odense University Hospital and University of Southern Denmark, Odense, Denmark
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11
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Hudon C, Lambert M, Aubrey-Bassler K, Chouinard MC, Doucet S, Ramsden VR, Zed J, Luke A, Bisson M, Howse D, Schwarz C, Rubenstein D, Taylor J. Fostering collective leadership to improve integrated primary care: lessons learned from the PriCARE program. Arch Public Health 2024; 82:24. [PMID: 38388457 PMCID: PMC10882827 DOI: 10.1186/s13690-024-01258-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/19/2024] [Indexed: 02/24/2024] Open
Abstract
Case management (CM) is an intervention for improving integrated care for patients with complex care needs. The implementation of this complex intervention often raises opportunities for change and collective leadership has the potential to optimize the implementation. However, the application of collective leadership in real-world is not often described in the literature. This commentary highlights challenges faced during the implantation of a CM intervention in primary care for people with complex care needs, including stakeholders' buy-in and providers' willingness to change their practice, selection of the best person for the case manager position and staff turnover. Based on lessons learned from PriCARE research program, this paper encourages researchers to adopt collective leadership strategies for the implementation of complex interventions, including promoting a collaborative approach, fostering stakeholders' engagement in a trusting and fair environment, providing a high level of communication, and enhancing collective leadership attitudes and skills. The learnings from the PriCARE program may help guide researchers for implementing complex healthcare interventions.
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Affiliation(s)
- Catherine Hudon
- Département de Médecine de Famille et de Médecine D'urgence, Université de Sherbrooke, 12e Avenue Nord, Sherbrooke, QC, 3001, Canada.
| | - Mireille Lambert
- Département de Médecine de Famille et de Médecine D'urgence, Université de Sherbrooke, 12e Avenue Nord, Sherbrooke, QC, 3001, Canada
| | - Kris Aubrey-Bassler
- Primary Healthcare Research Unit, Memorial University, Room 426, 4th Floor Janeway Hostel, Health Sciences Centre, 300 Prince Philip Dr, Saint John, NL, Canada
| | - Maud-Christine Chouinard
- Faculté des Sciences Infirmières, Université de Montréal, 2375, Chemin de la Côte-Ste-Catherine, Montréal, QC, Canada
| | - Shelley Doucet
- Department of Nursing and Health Sciences, University of New Brunswick, 100 Tucker Park Road, Saint John, NB, Canada
| | - Vivian R Ramsden
- Department of Academic Family Medicine, University of Saskatchewan, 3311 Fairlight Drive, Saskatoon, SK, Canada
| | - Joanna Zed
- Department of Family Medicine, Dalhousie University, 1465 Brenton Street, Halifax, NS, Canada
| | - Alison Luke
- Department of Nursing and Health Sciences, University of New Brunswick, 100 Tucker Park Road, Saint John, NB, Canada
| | - Mathieu Bisson
- Département de Médecine de Famille et de Médecine D'urgence, Université de Sherbrooke, 12e Avenue Nord, Sherbrooke, QC, 3001, Canada
| | - Dana Howse
- Primary Healthcare Research Unit, Memorial University, Room 426, 4th Floor Janeway Hostel, Health Sciences Centre, 300 Prince Philip Dr, Saint John, NL, Canada
| | - Charlotte Schwarz
- Department of Nursing and Health Sciences, University of New Brunswick, 100 Tucker Park Road, Saint John, NB, Canada
| | - Donna Rubenstein
- Department of Family Medicine, Dalhousie University, 1465 Brenton Street, Halifax, NS, Canada
| | - Jennifer Taylor
- Department of Nursing and Health Sciences, University of New Brunswick, 100 Tucker Park Road, Saint John, NB, Canada
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12
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Evans BA, Khanom A, Edwards A, Edwards B, Farr A, Foster T, Fothergill R, Gripper P, Gunson I, Porter A, Rees N, Scott J, Snooks H, Watkins A. Experiences and views of people who frequently call emergency ambulance services: A qualitative study of UK service users. Health Expect 2024; 27:e13856. [PMID: 37578195 PMCID: PMC10726061 DOI: 10.1111/hex.13856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/01/2023] [Accepted: 08/09/2023] [Indexed: 08/15/2023] Open
Abstract
INTRODUCTION People who call emergency ambulances frequently are often vulnerable because of health and social circumstances, have unresolved problems or cannot access appropriate care. They have higher mortality rates. Case management by interdisciplinary teams can help reduce demand for emergency services and is available in some UK regions. We report results of interviews with people who use emergency ambulance services frequently to understand their experiences of calling and receiving treatment. METHODS We used a two-stage recruitment process. A UK ambulance service identified six people who were known to them as frequently calling emergency services. Through third-sector organisations, we also recruited nine individuals with healthcare experiences reflecting the characteristics of people who call frequently. We gained informed consent to record and transcribe all telephone interviews. We used thematic analysis to explore the results. RESULTS People said they make frequent calls to emergency ambulance services as a last resort when they perceive their care needs are urgent and other routes to help have failed. Those with the most complex health needs generally felt their immediate requirements were not resolved and underlying mental and physical problems led them to call again. A third of respondents were also attended to by police and were arrested for behaviour associated with their health needs. Those callers receiving case management did not know they were selected for this. Some respondents were concerned that case management could label frequent callers as troublemakers. CONCLUSION People who make frequent calls to emergency ambulance services feel their health and care needs are urgent and ongoing. They cannot see alternative ways to receive help and resolve problems. Communication between health professionals and service users appears inadequate. More research is needed to understand service users' motivations and requirements to inform design and delivery of accessible and effective services. PATIENT OR PUBLIC CONTRIBUTION People with relevant experience were involved in developing, undertaking and disseminating this research. Two public contributors helped design and deliver the study, including developing and analysing service user interviews and drafting this paper. Eight public members of a Lived Experience Advisory Panel contributed at key stages of study design, interpretation and dissemination. Two more public contributors were members of an independent Study Steering Committee.
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Affiliation(s)
- Bridie A. Evans
- Swansea University Medical SchoolSwanseaUK
- PRIME Centre Wales, Institute of Life ScienceSwansea University Medical SchoolSwanseaUK
| | - Ashra Khanom
- Swansea University Medical SchoolSwanseaUK
- PRIME Centre Wales, Institute of Life ScienceSwansea University Medical SchoolSwanseaUK
| | - Adrian Edwards
- School of Medicine, PRIME Centre Wales, Division of Population MedicineCardiff UniversityCardiffUK
| | - Bethan Edwards
- Public Contributor, c/o Swansea University Medical SchoolSwanseaUK
| | - Angela Farr
- Swansea Centre for Health EconomicsSwansea UniversitySwanseaUK
| | | | | | - Penny Gripper
- Public Contributor, c/o Swansea University Medical SchoolSwanseaUK
| | - Imogen Gunson
- West Midlands Ambulance Service University NHS Foundation TrustWest MidlandsUK
| | - Alison Porter
- Swansea University Medical SchoolSwanseaUK
- PRIME Centre Wales, Institute of Life ScienceSwansea University Medical SchoolSwanseaUK
| | - Nigel Rees
- Welsh Ambulance Services NHS TrustCwmbranUK
| | | | - Helen Snooks
- Swansea University Medical SchoolSwanseaUK
- PRIME Centre Wales, Institute of Life ScienceSwansea University Medical SchoolSwanseaUK
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13
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Borde D, Agana-Norman DFG, Leverence R, Photos L, Shuster J, Lukose K, Pinkney J, Wright J, Waxenberg L, Allen B, Radhakrishnan NS. Outcomes of an integrated practice unit for vulnerable emergency department patients. BMC Health Serv Res 2023; 23:1449. [PMID: 38129783 PMCID: PMC10740262 DOI: 10.1186/s12913-023-10067-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 09/25/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND An integrated practice unit (IPU) that provides a multidisciplinary approach to patient care, typically involving a primary care provider, registered nurse, social worker, and pharmacist has been shown to reduce healthcare utilization among high-cost super-utilizer (SU) patients or multi-visit patients (MVP). However, less is known about differences in the impact of these interventions on insured vs. uninsured SU patients and super high frequency SUs ([Formula: see text]8 ED visits per 6 months) vs. high frequency SUs (4-7 ED visits per 6 months). METHODS We assessed the percent reduction in ED visits, ED cost, hospitalizations, hospital days, and hospitalization costs following implementation of an IPU for SUs located in an academic tertiary care facility. We compared outcomes for publicly insured with uninsured patients, and super high frequency SUs with high frequency SUs 6 months before vs. 6 months after enrollment in the IPU. RESULTS There was an overall 25% reduction in hospitalizations (p < 0.001), and 23% reduction in hospital days (p = 0.0045), when comparing 6 months before vs. 6 months after enrollment in the program. There was a 26% reduction in average total direct hospitalization costs per patient (p = 0.002). Further analysis revealed a greater reduction in health care utilization for uninsured SU patients compared with publicly insured patients. The program reduced hospitalizations for super high frequency SUs. However, there was no statistically significant impact on overall health care utilization of super high frequency SUs when compared with high frequency SUs. CONCLUSIONS Our study supports existing evidence that dedicated IPUs for SUs can achieve significant reductions in acute care utilization, particularly for uninsured and high frequency SU patients. TRIAL REGISTRATION IRB201500212. Retrospectively registered.
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Affiliation(s)
- Deepa Borde
- University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL, 32608, USA
| | | | - Robert Leverence
- University of Texas Health, 703 Floyd Curl Dr, San Antonio, TX, 78229, USA
| | - Lorrie Photos
- University of Florida Health, 1600 SW Archer Rd, Gainesville, FL, 32608, USA
| | - Jon Shuster
- University of Florida Health, 1600 SW Archer Rd, Gainesville, FL, 32608, USA
| | - Kiran Lukose
- University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL, 32608, USA
| | - Jacqueline Pinkney
- University of Florida Health, 1600 SW Archer Rd, Gainesville, FL, 32608, USA
| | - Joy Wright
- University of Florida Health, 1600 SW Archer Rd, Gainesville, FL, 32608, USA
| | - Lori Waxenberg
- University of Florida Health, 1600 SW Archer Rd, Gainesville, FL, 32608, USA
| | - Brandon Allen
- University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL, 32608, USA
| | - Nila S Radhakrishnan
- University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL, 32608, USA.
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Gabet M, Armoon B, Meng X, Fleury MJ. Effectiveness of emergency department based interventions for frequent users with mental health issues: A systematic review. Am J Emerg Med 2023; 74:1-8. [PMID: 37717467 DOI: 10.1016/j.ajem.2023.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/21/2023] [Accepted: 09/05/2023] [Indexed: 09/19/2023] Open
Abstract
Frequent emergency department (ED) users with mental health issues are particularly vulnerable patients, who often receive insufficient or inadequate outpatient care. This systematic review identified and evaluated studies on ED-based interventions to reduce acute care use by this population, while improving outpatient service use and patient outcomes. Searches were conducted in five databases for studies published between January 1, 2000, and April 30, 2022. Eligibility criteria included: patients with mental health issues who made 2+ ED visits in the previous 6 months or were high ED users (3+ visits/year), and who received ED-based interventions to reduce ED use. The review included 12 studies of 11,082 articles screened. Four intervention groups were identified: care plan (n = 4), case management (n = 4), peer-support (n = 2) and brief interventions (n = 2). The definitions of frequent users varied considerably, while the quality assessment rated studies from moderate to good and risk of bias from low to high. Eight studies used pre-post design, and four were randomized controlled trials. Ten studies assessed outcomes related to use of other services than ED, mainly hospitalizations, while five assessed patients' clinical conditions and three, social conditions (e.g., housing status). This review revealed that case management and care plan interventions, based in ED, decrease ED use among frequent users, while case management also showed promising results for outpatient service use and clinical and social outcomes. Thus, the results support continued deployment of intensive ED-based interventions for frequent ED users with mental health issues although firm conclusions regarding the effectiveness of these interventions, particularly outcomes related to services other than ED, require further investigation.
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Affiliation(s)
- Morgane Gabet
- Division of Mental Health & Society, Douglas Hospital Research Centre, Montreal, Canada; Département de Gestion, Evaluation et Politique de Santé, Université de Montréal, Montréal, Canada
| | - Bahram Armoon
- Division of Mental Health & Society, Douglas Hospital Research Centre, Montreal, Canada
| | - Xiangfei Meng
- Division of Mental Health & Society, Douglas Hospital Research Centre, Montreal, Canada
| | - Marie-Josée Fleury
- Division of Mental Health & Society, Douglas Hospital Research Centre, Montreal, Canada; Département de Gestion, Evaluation et Politique de Santé, Université de Montréal, Montréal, Canada; Department of Psychiatry, McGill University, Montreal, Canada.
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Delahunty-Pike A, Lambert M, Schwarz C, Howse D, Bisson M, Aubrey-Bassler K, Burge F, Chouinard MC, Doucet S, Luke A, Macdonald M, Zed J, Taylor J, Hudon C. Stakeholders' perceptions of a nurse-led telehealth case management intervention in primary care for patients with complex care needs: a qualitative descriptive study. BMJ Open 2023; 13:e073679. [PMID: 37844984 PMCID: PMC10582901 DOI: 10.1136/bmjopen-2023-073679] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 09/29/2023] [Indexed: 10/18/2023] Open
Abstract
OBJECTIVE With the onset of the COVID-19 pandemic, telehealth case management (TCM) was introduced in primary care for patients requiring care by distance. While not all healthcare needs can be addressed via telehealth, the use of information and communication technology to support healthcare delivery has the potential to contribute to the management of patients with chronic conditions and associated complex care needs. However, few qualitative studies have documented stakeholders' perceptions of TCM. This study aimed to describe patients', primary care providers' and clinic managers' perceptions of the use of a nurse-led TCM intervention for primary care patients with complex care needs. DESIGN Qualitative descriptive study. SETTING Three primary care clinics in three Canadian provinces. PARTICIPANTS Patients with complex care needs (n=30), primary care providers (n=11) and clinic managers (n=2) participated in qualitative individual interviews and focus groups. INTERVENTION TCM intervention was delivered by nurse case managers over a 6-month period. RESULTS Participants' perceptions of the TCM intervention were summarised in three themes: (1) improved patient access, comfort and sense of reassurance; (2) trusting relationships and skilled nurse case managers; (3) activities more suitable for TCM. TCM was a generally accepted mode of primary care delivery, had many benefits for patients and providers and worked well for most activities that do not require physical assessment or treatment. Participants found TCM to be useful and a viable alternative to in-person care. CONCLUSIONS TCM improves access to care and is successful when a relationship of trust between the nurse case manager and patient can develop over time. Healthcare policymakers and primary care providers should consider the benefits of TCM and promote this mode of delivery as a complement to in-person care for patients with complex care needs.
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Affiliation(s)
- Alannah Delahunty-Pike
- Primary Care Research Unit, Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Mireille Lambert
- Département de Médecine de Famille et de Médecine d'Urgence, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Charlotte Schwarz
- Department of Nursing and Health Sciences, University of New Brunswick, Saint. John, New Brunswick, Canada
| | - Dana Howse
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University, St. John's, Newfoundland and Labrador, Canada
| | - Mathieu Bisson
- Département de Médecine de Famille et de Médecine d'Urgence, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Kris Aubrey-Bassler
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University, St. John's, Newfoundland and Labrador, Canada
| | - Fred Burge
- Primary Care Research Unit, Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Shelley Doucet
- Department of Nursing and Health Sciences, University of New Brunswick, Saint. John, New Brunswick, Canada
| | - Alison Luke
- Department of Nursing and Health Sciences, University of New Brunswick, Saint. John, New Brunswick, Canada
| | - Marilyn Macdonald
- Primary Care Research Unit, Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Joanna Zed
- Primary Care Research Unit, Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Catherine Hudon
- Département de Médecine de Famille et de Médecine d'Urgence, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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Giannouchos T, Pirrallo R, Ukert B. Factors associated with persistent multiyear frequent emergency department use. Emerg Med J 2023; 40:589-595. [PMID: 37164623 DOI: 10.1136/emermed-2022-212740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 04/25/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Although frequent emergency department (ED) users have been widely studied in cross-sectional settings, there is some evidence suggesting that most frequent ED users do not remain frequent users over multiple consecutive years. The objective of this study was to explore the association between persistent multiyear frequent ED use and individuals' characteristics. METHODS A retrospective analysis using the Healthcare Cost and Utilization Project State Emergency Department Databases (2012-2017) for individuals aged 18-59 who visited any ED in Florida, Massachusetts and New York was conducted. Multivariable regression models were used to estimate the association between persistent frequent ED use over time (≥4 ED visits in each data year) and individuals' characteristics and clinical factors compared with non-persistent frequent users (≥4 ED visits only in the baseline year). RESULTS The databases for the three states included 3.3 million patients, who accounted for 4.5 million ED visits in the baseline year (2012). Of those, 3.2% of patients were frequent ED users (≥4 visits) accounting for 13.2% of all ED visits in the baseline year. Longitudinal follow-up revealed that 14.9% (15 617) of frequent users in 2012 remained persistently frequent ED users for 2-3 consecutive years and 3.6% (3774) for 4-6 consecutive years. Persistent frequent ED users differed significantly from non-persistent frequent ED users; they had more ED visits in the index year, were more likely to have no health insurance or public health insurance coverage, and had a higher prevalence of chronic conditions and comorbidities, and more ED visits for less medically urgent conditions. CONCLUSION Differences exist between persistent and non-persistent frequent ED users that should be considered when implementing interventions designed to improve health outcomes and curtail healthcare expenditures generated by the broad population of frequent ED users.
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Affiliation(s)
- Theodoros Giannouchos
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Ronald Pirrallo
- School of Medicine, University of South Carolina, Greenville, South Carolina, USA
- Department of Emergency Medicine, Prisma Health, Greenville, South Carolina, USA
| | - Benjamin Ukert
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, Texas, USA
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Naït Salem R, Rotily M, Apostolidis T, Odena S, Lamouroux A, Chischportich C, Persico N, Auquier P. Health mediation: an intervention mode for improving emergency department care and support for patients living in precarious conditions. BMC Health Serv Res 2023; 23:495. [PMID: 37194100 PMCID: PMC10186303 DOI: 10.1186/s12913-023-09522-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/09/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Severe overcrowding of emergency departments (EDs) impacts the quality of healthcare. One factor of this overcrowding is precariousness, but it has rarely been considered a key factor in designing interventions to improve ED care. Health mediation (HM) aims to facilitate access to rights, prevention, and care for the most vulnerable persons and to raise awareness among healthcare providers about obstacles in accessing healthcare. We here present the results of an ancillary qualitative study to explore the prospects regarding a health mediation intervention implemented in EDs for deprived persons who are frequent ED users, from professionals' and patients' perspectives. METHODS Design, data collection, and data analysis were done according to a psychosocial approach, based on thematic content analysis and semi-structured interviews of 16 frequent ED users and deprived patients exposed to HM and of 14 professionals in 4 EDs of South-eastern France. RESULTS All patients reported multifactorial distress. Most of them expressed experiencing isolation and powerlessness, and lacking personal resources to cope with healthcare. They mentioned the use of ED as a way of quickly meeting a professional to respond to their suffering, and recognized the trustworthy alliance with health mediators (HMrs) as a means to put them back in a healthcare pathway. The presence of HMrs in EDs was appreciated by ED professionals because HMrs responded to requests they were not able to access and were perceived as an efficient support for caring for deprived persons in emergency contexts. CONCLUSIONS Our results are in favour of health mediation in EDs as a promising solution, requested by patients and ED professionals, to cope with frequent ED users and deprived patients. Our results could also be used to adapt other strategies for the most vulnerable populations to reduce the frequency of ED readmissions. At the interface of the patients' health experience and the medico-social sector, HM could complete the immediate responses to medical needs given in EDs and contribute in alleviating the social inequalities of health.
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Affiliation(s)
- Riwan Naït Salem
- Laboratoire de Psychologie Sociale (LPS), Aix Marseille Université, Aix-en-Provence, France
| | - Michel Rotily
- Centre de Santé Universitaire - Espace Santé Aygalades - Assistance Publique Hopitaux de Marseille, Marseille, France.
- Centre d'Etudes et de Recherche sur les services de santé et la qualité de vie (CEReSS), Aix Marseille Université, Marseille, France.
| | | | - Sophie Odena
- Aix Marseille Univ, CNRS, LEST, Aix-en-Provence, France
| | - Aurore Lamouroux
- Centre de Santé Universitaire - Espace Santé Aygalades - Assistance Publique Hopitaux de Marseille, Marseille, France
| | | | - Nicolas Persico
- Service d'Accueil des Urgences Adultes, Hopital Nord, Assistance Publique Hopitaux de Marseille, Marseille, France
| | - Pascal Auquier
- Centre d'Etudes et de Recherche sur les services de santé et la qualité de vie (CEReSS), Aix Marseille Université, Marseille, France
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Graells M, Schaad L, Schmutz E, Moullin J, Hugli O, Daeppen JB, Ambrosetti J, Ombelli J, Golay M, Ribordy V, Bodenmann P, Grazioli VS. Experiences of Frequent Users of Emergency Departments in Health Care Setting in French-Speaking Switzerland: A Qualitative Study. Healthcare (Basel) 2023; 11:healthcare11091228. [PMID: 37174770 PMCID: PMC10178271 DOI: 10.3390/healthcare11091228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 05/15/2023] Open
Abstract
AIMS Frequent users of the emergency department (FUED; five ED visits or more per year) often have negative experiences in health care settings, potentially aggravating their health problems. Scarce research has explored FUED experiences in health care in Europe, none in Switzerland. Thus, this study aimed to conduct an in-depth exploration of FUED experiences in health care settings in Switzerland. METHODS Semi-structured interviews were conducted among 20 FUED (75% female; mean age = 40.6, SD = 12.8). Qualitative data were subject to inductive content analysis. RESULTS Five main themes emerged from the analysis. The main findings documented that FUED experiences in health care were mostly negative, leading to negative emotions, dissatisfaction and a loss of confidence in the system, although some positive experiences were reported as well. The relationship with health care workers was perceived as playing a key role in FUED experiences. CONCLUSION The findings indicate that FUED often have negative experiences in the health care system in Switzerland. The relationship with the health care staff is reported as a decisive ingredient of the experience in health care. Future research is needed to develop awareness-raising interventions for health care staff to improve FUED experiences in health care.
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Affiliation(s)
- Madison Graells
- Department of Vulnerabilities and Social Medicine, Center for Primary Care and Public Health, University of Lausanne, 1011 Lausanne, Switzerland
| | - Luana Schaad
- Department of Vulnerabilities and Social Medicine, Center for Primary Care and Public Health, University of Lausanne, 1011 Lausanne, Switzerland
| | - Elodie Schmutz
- Department of Vulnerabilities and Social Medicine, Center for Primary Care and Public Health, University of Lausanne, 1011 Lausanne, Switzerland
| | - Joanna Moullin
- Faculty Health Sciences, School of Population Health, Curtin University, Perth 6845, Australia
| | - Olivier Hugli
- Emergency Department, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Jean-Bernard Daeppen
- Addiction Medicine, Department of Psychiatry, Lausanne University Hospital, 1011 Lausanne, Switzerland
| | - Julia Ambrosetti
- Emergency Department, Geneva University Hospital, 1205 Geneva, Switzerland
| | - Julien Ombelli
- Emergency Department, North Vaud Hospital Group, 1400 Yverdon-les-Bains, Switzerland
| | - Michel Golay
- Emergency Department, La Broye Hospital, 1530 Payerne, Switzerland
| | - Vincent Ribordy
- Emergency Department, Fribourg Hospital, 1700 Fribourg, Switzerland
| | - Patrick Bodenmann
- Department of Vulnerabilities and Social Medicine, Center for Primary Care and Public Health, University of Lausanne, 1011 Lausanne, Switzerland
| | - Véronique S Grazioli
- Department of Vulnerabilities and Social Medicine, Center for Primary Care and Public Health, University of Lausanne, 1011 Lausanne, Switzerland
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19
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Cariello C, Grazioli VS, Nikles J, Schmutz E, Hugli O, Bodenmann P. Understanding the experience in the healthcare system of non-migrant and migrant frequent users of the emergency department in French-speaking Switzerland: a comparative qualitative study. BMJ Open 2023; 13:e069272. [PMID: 37094894 PMCID: PMC10151913 DOI: 10.1136/bmjopen-2022-069272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 04/05/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND Previous research revealed the vulnerability of frequent users of emergency department (FUED) because of concomitant medical, psychological and social issues. Case management (CM) provides FUED with effective medical and social support, however, the heterogeneity of this population has highlighted the need to explore the specific needs of FUED subpopulations. In response, this study aimed to explore qualitatively the lived experience of migrant and non-migrant FUED in the healthcare system to identify unmet needs. METHODS Adult migrant and non-migrant FUED (≥ 5 visits in the ED in the past 12 months) were recruited in a Swiss university hospital to collect qualitative data on their experience within the Swiss health system. Participants were selected based on predefined quotas for gender and age. Researchers conducted one-on-one semistructured interviews until reaching data saturation. Inductive conventional content analysis was used to analyse qualitative data. RESULTS In total, 23 semistructured interviews were conducted (11 migrant FUED and 12 non-migrant FUED). Four main themes emerged from the qualitative analysis: (1) self-evaluation of the Swiss healthcare system; (2) orientation within the healthcare system; (3) relationship with caregivers and (4) perception of own health. While both groups were overall satisfied with the healthcare system and care provided, migrant FUED reported language and financial barriers to access it. Both groups expressed overall satisfaction over their relationship with healthcare professionals, although migrant FUED reported a feeling of illegitimacy to consult the ED based on social status, whereas non-migrant FUED felt more often the need to justify their use of the ED. Finally, migrant FUED perceived their own health to be affected by their status. CONCLUSION This study highlighted difficulties specific to subpopulations of FUED. For migrant FUED, these included access to care and impact of migrant status on own health. Adapting CM to the specific needs of migrant FUED could help reduce their vulnerability.
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Affiliation(s)
- Carmen Cariello
- Department of Vulnerabilities and Social Medicine, Center for Primary Care and Public Health, Chair of Medicine for Vulnerable Populations, University of Lausanne, Lausanne, Switzerland
| | - Véronique S Grazioli
- Department of Vulnerabilities and Social Medicine, Center for Primary Care and Public Health, Chair of Medicine for Vulnerable Populations, University of Lausanne, Lausanne, Switzerland
| | - Justin Nikles
- Department of Vulnerabilities and Social Medicine, Center for Primary Care and Public Health, Chair of Medicine for Vulnerable Populations, University of Lausanne, Lausanne, Switzerland
| | - Elodie Schmutz
- Department of Vulnerabilities and Social Medicine, Center for Primary Care and Public Health, Chair of Medicine for Vulnerable Populations, University of Lausanne, Lausanne, Switzerland
| | - Olivier Hugli
- Emergency Department, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Patrick Bodenmann
- Department of Vulnerabilities and Social Medicine, Center for Primary Care and Public Health, Chair of Medicine for Vulnerable Populations, University of Lausanne, Lausanne, Switzerland
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20
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Hudon C, Bisson M, Chouinard MC, Delahunty-Pike A, Lambert M, Howse D, Schwarz C, Dumont-Samson O, Aubrey-Bassler K, Burge F, Doucet S, Ramsden VR, Luke A, Macdonald M, Gaudreau A, Porter J, Rubenstein D, Scott C, Warren M, Wilhelm L. Implementation analysis of a case management intervention for people with complex care needs in primary care: a multiple case study across Canada. BMC Health Serv Res 2023; 23:377. [PMID: 37076851 PMCID: PMC10116737 DOI: 10.1186/s12913-023-09379-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 04/08/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Case management is one of the most frequently performed interventions to mitigate the negative effects of high healthcare use on patients, primary care providers and the healthcare system. Reviews have addressed factors influencing case management interventions (CMI) implementation and reported common themes related to the case manager role and activities, collaboration with other primary care providers, CMI training and relationships with the patients. However, the heterogeneity of the settings in which CMI have been implemented may impair the transferability of the findings. Moreover, the underlying factors influencing the first steps of CMI implementation need to be further assessed. This study aimed to evaluate facilitators and barriers of the first implementation steps of a CMI by primary care nurses for people with complex care needs who frequently use healthcare services. METHODS A qualitative multiple case study was conducted including six primary care clinics across four provinces in Canada. In-depth interviews and focus groups with nurse case managers, health services managers, and other primary care providers were conducted. Field notes also formed part of the data. A mixed thematic analysis, deductive and inductive, was carried out. RESULTS Leadership of the primary care providers and managers facilitated the first steps of the of CMI implementation, as did the experience and skills of the nurse case managers and capacity development within the teams. The time required to establish CMI was a barrier at the beginning of the CMI implementation. Most nurse case managers expressed apprehension about developing an "individualized services plan" with multiple health professionals and the patient. Clinic team meetings and a nurse case managers community of practice created opportunities to address primary care providers' concerns. Participants generally perceived the CMI as a comprehensive, adaptable, and organized approach to care, providing more resources and support for patients and better coordination in primary care. CONCLUSION Results of this study will be useful for decision makers, care providers, patients and researchers who are considering the implementation of CMI in primary care. Providing knowledge about first steps of CMI implementation will also help inform policies and best practices.
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Affiliation(s)
- Catherine Hudon
- Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Pavillon Z7-Room 3007, 3001, 12E Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada.
- Centre Hospitalier Universitaire de Sherbrooke Research Centre, Sherbrooke, QC, Canada.
| | - Mathieu Bisson
- Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Pavillon Z7-Room 3007, 3001, 12E Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada
| | | | | | - Mireille Lambert
- Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Pavillon Z7-Room 3007, 3001, 12E Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada
| | - Dana Howse
- Primary Healthcare Research Unit, Memorial University, St-John's, NL, Canada
| | - Charlotte Schwarz
- Department of Nursing and Health Sciences, University of New Brunswick, Fredericton, NB, Canada
| | - Olivier Dumont-Samson
- Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Pavillon Z7-Room 3007, 3001, 12E Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada
| | - Kris Aubrey-Bassler
- Primary Healthcare Research Unit, Memorial University, St-John's, NL, Canada
| | - Fred Burge
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Shelley Doucet
- Department of Nursing and Health Sciences, University of New Brunswick, Fredericton, NB, Canada
| | - Vivian R Ramsden
- Department of Academic Family Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Alison Luke
- Department of Nursing and Health Sciences, University of New Brunswick, Fredericton, NB, Canada
| | - Marilyn Macdonald
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | | | - Judy Porter
- Nova Scotia Health Authority, Halifax, NS, Canada
| | | | - Cathy Scott
- Canadian Cancer Society, Toronto, ON, Canada
| | - Mike Warren
- Patient Advisory Council, Newfoundland and Labrador SPOR SUPPORT Unit, St. John's, NL, Canada
| | - Linda Wilhelm
- Canadian Arthritis Patient Alliance, Ottawa, ON, Canada
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21
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Furia G, Vinci A, Colamesta V, Papini P, Grossi A, Cammalleri V, Chierchini P, Maurici M, Damiani G, De Vito C. Appropriateness of frequent use of emergency departments: A retrospective analysis in Rome, Italy. Front Public Health 2023; 11:1150511. [PMID: 37081951 PMCID: PMC10110884 DOI: 10.3389/fpubh.2023.1150511] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 02/28/2023] [Indexed: 04/07/2023] Open
Abstract
BackgroundFrequent users (FUs) are patients who repeatedly and inappropriately visit the emergency department (ED) for low-grade symptoms that could be treated outside the hospital setting. This study aimed to investigate the phenomenon of the FU in Rome by profiling such users and analyzing ED attendance by FUs.MethodsThe analysis was carried out for attendance in 2021 at 15 EDs in the Local Health Authority Roma 1 geographical area. A digital app collected data, including information on the following variables: number of attendance, demographic characteristics, emergency medical service (EMS) usage, triage code, and appropriateness of attendance. COVID-19 diagnosis was also studied to analyze any possible influence on ED attendance. Differences between FUs and non-FUs were investigated statistically by t-test and chi-square test. Univariate analysis and multivariable logistic regression were performed to analyze the associated factors.ResultsA total of 122,762 ED attendance and 89,036 users were registered. The FU category represented 2.9% of all users, comprising 11.9% of total ED attendance. There was a three times higher frequency of non-urgent codes in attendance of FU patients (FU: 9.7%; non-FU: 3.2%). FUs were slightly more likely to have used the EMS (13.6% vs. 11.4%) and had a lower frequency of appropriate ED attendance (23.8% vs. 27.0%). Multivariate logistic analysis confirmed a significant effect of triage code, gender, age, EMS usage, and COVID-19 diagnosis for the appropriateness of attendance. The results were statistically significant (p < 0.001).ConclusionThe FU profile describes mostly non-urgent and inappropriate attendance at the ED, including during the COVID-19 pandemic. This study represents an important tool for strengthening preventive policies outside the hospital setting. The Italian National Recovery and Resilience Plan represents an excellent opportunity for the development of new strategies to mitigate the phenomenon of FUs.
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Affiliation(s)
- Giuseppe Furia
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
- Local Health Authority Roma 1, Borgo Santo Spirito, Rome, Italy
- *Correspondence: Giuseppe Furia
| | - Antonio Vinci
- Local Health Authority Roma 1, Borgo Santo Spirito, Rome, Italy
- Nursing Sciences and Public Health, University of Rome “Tor Vergata”, Rome, Italy
| | | | - Paolo Papini
- Local Health Authority Roma 1, Borgo Santo Spirito, Rome, Italy
| | - Adriano Grossi
- Local Health Authority Roma 1, Borgo Santo Spirito, Rome, Italy
| | - Vittoria Cammalleri
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | | | - Massimo Maurici
- Department of Biomedicine and Prevention, University of Rome “Tor Vergata”, Rome, Italy
| | - Gianfranco Damiani
- Section of Hygiene, University Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Corrado De Vito
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
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Hudon C, Chouinard MC, Dumont-Samson O, Gobeil-Lavoie AP, Morneau J, Paradis M, Couturier Y, Poitras ME, Poder T, Sabourin V, Lambert M. Integrated case management between primary care clinics and hospitals for people with complex needs who frequently use healthcare services: A multiple-case embedded study. Health Policy 2023; 132:104804. [PMID: 37028261 DOI: 10.1016/j.healthpol.2023.104804] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/29/2023] [Accepted: 04/02/2023] [Indexed: 04/05/2023]
Abstract
INTRODUCTION Case management (CM) is recognized to improve care integration and outcomes of people with complex needs who frequently use healthcare services, but challenges remain regarding interaction between primary care clinics and hospitals. This study aimed to implement and evaluate an integrated CM program for this population where nurses in primary care clinics worked with a hospital case manager. METHODS A multiple embedded case study was conducted in the Saguenay-Lac-Saint-Jean region (Québec, Canada), in four dyads including a clinic and a hospital. Mixed data collection included, at baseline and 6 months, interviews and focus groups with stakeholders, patient questionnaires (patient experience of integrated care and self-management), and emergency department (ED) visits in the previous 6 months. RESULTS Integrated CM implementation was optimal when all stakeholders provided collective leadership, and were supportive of the program, particularly the physicians. The 6-month program enabled the observation of positive qualitative outcomes in most clinic-hospital dyads where implementation occurred. Full implementation was associated with improved care integration. DISCUSSION AND CONCLUSION Integrated CM between primary care clinics and hospitals is a promising innovation to improve care integration for people with complex needs who frequently use healthcare services. Collective leadership and physicians' buy-in to integrated CM are important to foster the implementation.
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de Souza Amarante LC, Gonçalo Mialhe C, Guerra LM, Vilela Bugarelli de Faria J, Mialhe FL. [Reasons given by patients for inappropriate use of emergency medical services]. Rev Salud Publica (Bogota) 2023; 22:440-446. [PMID: 36753244 DOI: 10.15446/rsap.v22n4.54092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 06/12/2020] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE The aim of this study was investígate the reasons for the demand for these services by users rated on two non-urgent emergency care units of a medium-sized municipality of São Paulo. METHODOLOGY Qualitative data were collected through semi-structured interviews with 756 individuals who sought the services of emergency care units and, of these, 417 (55%) users were classified as non-urgent risk and were eligible for the study. RESULTS It was observed six major categories of motives among that seeking care in emergency care units: lack of infrastructure of the nearest health unit; perception of pain and symptoms of emergency; home/work proximity; takes care of scheduling and primary health care; quality of care in the emergency care units; habit of attending services. These categories were grouped into four themes concerning: a) perception of urgency; b) convenience; c) difficulty of access and d) quality of service. CONCLUSION It was concluded from these findings the need to strengthen primary care system in order to ensure facilitated access for users and better resolution of cases that can be seen treated in this level, in conjunction with the entire network of health care.
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Affiliation(s)
- Lidiane Cintia de Souza Amarante
- LA: Enfermeira. M. Sc. Saúde Coletiva. Complexo Hospital de Clínicas da Universidade Federal do Paraná (UFPR). Curitiba/PR, Brasil.
| | - Camila Gonçalo Mialhe
- CM: Cirurgiã-Dentista. Ph. D. Saúde Coletiva. Faculdade de Medicina de Jundiaí. Jundiaí/SP, Brasil.
| | - Luciane Miranda Guerra
- LG: Cirurgiã-Dentista. Ph.D. Saúde Coletiva. Faculdade de Odontologia. Universidade Estadual de Campinas (UNICAMP). Piracicaba/SP, Brasil.
| | | | - Fábio Luiz Mialhe
- FM: Cirurgião-Dentista. Ph.D. Saúde Coletiva. Faculdade de Odontologia. Universidade Estadual de Campinas (UNICAMP). Piracicaba/SP, Brasil.
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Hudon C, Kessler R. Integrating case management for patients with complex needs in the ground practice: the importance of context in evaluative designs. Health Res Policy Syst 2023; 21:9. [PMID: 36694260 PMCID: PMC9873218 DOI: 10.1186/s12961-023-00960-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 01/09/2023] [Indexed: 01/26/2023] Open
Abstract
Responding to complex needs calls for integrating care across providers, settings and sectors. Among models to improve integrated care, case management demonstrates a good evidence base of facilitating the appropriate delivery of healthcare services. Since case management is a complex, multi component intervention, with its component parts interacting in a non-linear manner, effectiveness is largely influenced by the context in which the intervention is implemented. This paper discusses how to respond to implementation challenges to evaluating complex interventions for patients with complex needs. Building on the example of case management, we suggest that documenting innovation effectiveness remains important, but that evaluation needs to include theory-based and systems perspectives. We also suggest that implementation science needs to be part of intervention design while engaging stakeholders to define the most relevant research questions and implementation effectiveness, to optimize successful implementation and sustainability.
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Affiliation(s)
- Catherine Hudon
- grid.86715.3d0000 0000 9064 6198Department of Family and Emergency Medicine, Université de Sherbrooke, Pavillon Z7-local 3007, 3001, 12eAvenue Nord, Sherbrooke, QC J1H 5N4 Canada
| | - Rodger Kessler
- grid.430503.10000 0001 0703 675XDepartment of Family Medicine, University of Colorado School of Medecine, Aurora, CO United States of America
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Vongsachang H, Schneberk T, Sprunt L, Padilla G, Riddell J. The Impact of an Experiential Social Medicine Curriculum in an Emergency Medicine Residency Training Program: Mixed-methods Curricular Evaluation. West J Emerg Med 2023; 24:83-88. [PMID: 36602495 PMCID: PMC9897255 DOI: 10.5811/westjem.2022.10.57724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 10/19/2022] [Indexed: 01/06/2023] Open
Affiliation(s)
- Hurnan Vongsachang
- Los Angeles County + University of Southern California Medical Center, Department of Emergency Medicine, Los Angeles, California
| | - Todd Schneberk
- Los Angeles County + University of Southern California Medical Center, Department of Emergency Medicine, Los Angeles, California
| | - Laura Sprunt
- Temple University Hospital, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Gabe Padilla
- Rhode Island Hospital and Brown Emergency Medicine Residency, Providence, Rhode Island
| | - Jeff Riddell
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, California
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Schaad L, Graells M, Kasztura M, Schmutz E, Moullin J, Hugli O, Daeppen JB, Ambrosetti J, Ombelli J, Golay M, Ribordy V, Grazioli VS, Bodenmann P. Perspectives of Frequent Users of Emergency Departments on a Case Management Intervention: A Qualitative Study. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2023; 60:469580231159745. [PMID: 36927138 PMCID: PMC10026145 DOI: 10.1177/00469580231159745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
BACKGROUND Effective management of frequent users of emergency departments (FUED) remains challenging. Case management (CM) has shown to improve patient quality of life while reducing ED visits and associated costs. However, little data is available on FUED's perception of CM outside of North America to further improve CM implementation. OBJECTIVES Explore the FUED's perspectives about CM in Switzerland. DESIGN, SETTING & PARTICIPANTS Semi-structured qualitative interviews eliciting FUED's experiences of CM were conducted among 20 participants (75% female; mean age = 40.6, SD = 12.8) across 6 hospital ED. OUTCOMES MEASURES & ANALYSIS Inductive content analysis. MAIN RESULTS Most participants were satisfied with the CM program. In particular, FUEDs identified the working relationship with the case manager (cm) as key for positive outcomes, and also valued the holistic evaluation of their needs and resources. Overall, patients reported increased motivation and health literacy, as well as facilitated interactions within the healthcare system. Conversely, a small number of participants reported negative views on CM (ie, stigmatization, lack of concrete outcomes). Barriers identified were cm's lack of time, COVID-19's negative impact on CM organization, as well as lack of clarity on the objectives of CM. FUED perceived CM as useful, in particular establishing a working relationship with the cm. Our results suggest that CM can be further improved by (1) professionals remaining non-judgmental toward FUED, (2) making sure the aims and objectives of the CM are understood by the participants, and (3) allowing more time for the cm to carry out their work.
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Affiliation(s)
- Luana Schaad
- Department of Vulnerabilities and Social Medicine, Center for Primary Care and Public Health, Chair of Medicine for Vulnerable Populations, Lausanne University, Switzerland
| | - Madison Graells
- Department of Vulnerabilities and Social Medicine, Center for Primary Care and Public Health, Chair of Medicine for Vulnerable Populations, Lausanne University, Switzerland
| | - Miriam Kasztura
- Department of Vulnerabilities and Social Medicine, Center for Primary Care and Public Health, Chair of Medicine for Vulnerable Populations, Lausanne University, Switzerland
| | - Elodie Schmutz
- Department of Vulnerabilities and Social Medicine, Center for Primary Care and Public Health, Chair of Medicine for Vulnerable Populations, Lausanne University, Switzerland
| | | | - Olivier Hugli
- Department of Vulnerabilities and Social Medicine, Center for Primary Care and Public Health, Chair of Medicine for Vulnerable Populations, Lausanne University, Switzerland
| | - Jean-Bernard Daeppen
- Department of Vulnerabilities and Social Medicine, Center for Primary Care and Public Health, Chair of Medicine for Vulnerable Populations, Lausanne University, Switzerland
| | | | - Julien Ombelli
- North Vaud Hospital Group, Yverdon-les-Bains, Switzerland
| | - Michel Golay
- Broye Intercantonal Hospital, Payerne, Switzerland
| | | | - Véronique S Grazioli
- Department of Vulnerabilities and Social Medicine, Center for Primary Care and Public Health, Chair of Medicine for Vulnerable Populations, Lausanne University, Switzerland
| | - Patrick Bodenmann
- Department of Vulnerabilities and Social Medicine, Center for Primary Care and Public Health, Chair of Medicine for Vulnerable Populations, Lausanne University, Switzerland
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An observational pilot study: Prevalence and cost of high frequency emergency department users at Örebro University Hospital, Sweden. PLoS One 2022; 17:e0274622. [PMID: 36107928 PMCID: PMC9477344 DOI: 10.1371/journal.pone.0274622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 08/31/2022] [Indexed: 11/26/2022] Open
Abstract
Background There is little research on high frequency emergency department users (HEDU) in Sweden. We aim to determine the prevalence and costs of HEDU compared to non-HEDU at Örebro University Hospital (ÖUH). Additionally, we will determine the factors and outcomes associated with being a HEDU. Methods This was a retrospective, observational cohort study of ED patients presenting to ÖUH, Sweden between 2018–19. Analyses used electronic registry, ambulance, and cost data. The definition for HEDU was ≥4 visits/year. HEDUs were categorized further into Repeat, High and Super HEDU with 4–7, 8–18 and ≥19 visits/year, respectively. We used multivariable logistic regression to determine the adjusted odds ratios for factors and outcomes between HEDU and non-HEDU. Findings Of all ÖUH ED patients, 6.1% were HEDU and accounted for 22.4% of ED visits and associated costs. Compared to the mean cost of non-HEDU, the Repeat, High and Super HEDU were more costly by factors of 4, 8 and 27, respectively. The HEDUs were more likely to be male, self-referred, present with abdominal pain, arrive by ambulance, at night and from the Örebro municipal region. Super HEDU were more likely to be of adult age and assigned lower acuity scores. HEDU were more likely to be directed to the surgical zone, less likely to receive radiologic imaging or achieve a 4-hr time target. In contrast to the Repeat and High HEDU, Super HEDU were less likely to be admitted, but more likely to leave without being seen. Conclusion ÖUH has a HEDU population with associated factors and outcomes. They account for a substantial proportion of ED costs compared to non-HEDU.
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Aslam RW, Snooks H, Porter A, Khanom A, Cole R, Edwards A, Edwards B, Evans BA, Foster T, Fothergill R, Gripper P, John A, Petterson R, Rosser A, Tee A, Sewell B, Hughes H, Phillips C, Rees N, Scott J, Watkins A. STRategies to manage Emergency ambulance Telephone Callers with sustained High needs: an Evaluation using linked Data (STRETCHED) - a study protocol. BMJ Open 2022; 12:e053123. [PMID: 35351702 PMCID: PMC8966558 DOI: 10.1136/bmjopen-2021-053123] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 01/28/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION UK ambulance services have identified a concern with high users of the 999 service and have set up 'frequent callers' services, ranging from within-service management to cross-sectoral multidisciplinary case management approaches. There is little evidence about how to address the needs of this patient group. AIM To evaluate effectiveness, safety and efficiency of case management approaches to the care of people who frequently call the emergency ambulance service, and gain an understanding of barriers and facilitators to implementation. OBJECTIVES (1) Develop an understanding of predicted mechanisms of change to underpin evaluation. (2) Describe epidemiology of sustained high users of 999 services. (3) Evaluate case management approaches to the care of people who call the 999 ambulance service frequently in terms of: (i) Further emergency contacts (999, emergency department, emergency admissions to hospital) (ii) Effects on other services (iii) Adverse events (deaths, injuries, serious medical emergencies and police arrests) (iv) Costs of intervention and care (v) Patient experience of care. (4) Identify challenges and opportunities associated with using case management models, including features associated with success, and develop theories about how case management works in this population. METHODS AND ANALYSIS We will conduct a multisite mixed-methods evaluation of case management for people who use ambulance services frequently by using anonymised linked routine data outcomes in a 'natural experiment' cohort design, in four regional ambulance services. We will conduct interviews and focus groups with service users, commissioners and emergency and non-acute care providers. The planned start and end dates of the study are 1 April 2019 and 1 September 2022, respectively ETHICS AND DISSEMINATION: The study received approval from the UK Health Research Authority (Confidentiality Advisory Group reference number: 19/CAG/0195; research ethics committee reference number: 19/WA/0216).We will collate feedback from our Lived Experience Advisory Panel, the Frequent Caller National Network and Research Management Group for targeted dissemination activities.
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Affiliation(s)
- Rabeea'h W Aslam
- Swansea University Medical School, Swansea University, Swansea, Wales, UK
| | - Helen Snooks
- Swansea University Medical School, Swansea University, Swansea, Wales, UK
| | - Alison Porter
- Swansea University Medical School, Swansea University, Swansea, Wales, UK
| | | | - Robert Cole
- West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill, UK
| | - Adrian Edwards
- Division of Population Medicine, Cardiff University, Cardiff, Wales, UK
| | - Bethan Edwards
- Swansea University Medical School, Swansea University, Swansea, Wales, UK
| | | | - Theresa Foster
- East of England Ambulance Service NHS Trust, Melbourn, UK
| | | | - Penny Gripper
- Swansea University Medical School, Swansea University, Swansea, Wales, UK
| | - Ann John
- Swansea University Medical School, Swansea University, Swansea, Wales, UK
| | | | - Andy Rosser
- West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill, UK
| | - Anna Tee
- Swansea University Medical School, Swansea University, Swansea, Wales, UK
| | - Bernadette Sewell
- College of Human and Health Sciences, Swansea University, Swansea, UK
| | - Heather Hughes
- Swansea University Medical School, Swansea University, Swansea, Wales, UK
| | - Ceri Phillips
- College of Human and Health Sciences, Swansea University, Swansea, UK
| | - Nigel Rees
- Pre-Hospital Emergency Research Unit, Welsh Ambulance Service NHS Trust, Swansea, UK
| | - Jason Scott
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Alan Watkins
- Swansea University Medical School, Swansea University, Swansea, Wales, UK
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Fleury MJ, Grenier G, Cao Z, Huỳnh C. Predictors of no, low and frequent emergency department use for any medical reason among patients with cannabis-related disorders attending Quebec (Canada) addiction treatment centres. Drug Alcohol Rev 2022; 41:1136-1151. [PMID: 35266240 DOI: 10.1111/dar.13451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 01/30/2022] [Accepted: 01/30/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Patients with substance-related disorders and mental disorders (MD) contribute substantially to emergency department (ED) overcrowding. Few studies have identified predictors of ED use integrating service use correlates, particularly among patients with cannabis-related disorders (CRD). This study compared predictors of low (1-2 visits/year) or frequent (3+ visits/year) ED use with no ED use for a cohort of 9836 patients with CRD registered at Quebec (Canada) addiction treatment centres in 2012-2013. METHODS This longitudinal study used multinomial logistic regression to evaluate clinical, sociodemographic and service use variables from various databases as predictors of the frequency of ED use for any medical reason in 2015-2016 among patients with CRD. RESULTS Compared to non-ED users with CRD, frequent ED users included more women, rural residents, patients with serious MD and chronic CRD, dropouts from programs in addiction treatment centres and with less continuity of physician care. Compared with non-users, low ED users had more common MD and there more workers than students. DISCUSSION AND CONCLUSIONS Multimorbidity, including MD, chronic physical illnesses and other substance-related disorders than CRD, predicted more ED use and explained frequent use of outpatient services and prior specialised acute care, as did being 12-29 years, after controlling for all other covariates. Better continuity of physician care and reinforcement of programs like assertive community or integrated treatment, and chronic primary care models may protect against frequent ED use. Strategies like screening, brief intervention and treatment referral, including motivational therapy for preventing treatment dropout may also be expanded to decrease ED use.
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Affiliation(s)
- Marie-Josée Fleury
- Department of Psychiatry, McGill University, Montreal, Canada.,Douglas Hospital Research Centre, Douglas Mental Health University Institute, Montreal, Canada
| | - Guy Grenier
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, Montreal, Canada
| | - Zhirong Cao
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, Montreal, Canada
| | - Christophe Huỳnh
- Institut Universitaire sur les Dépendances, Centre Intégré Universitaire de Santé et des Services Sociaux du Centre-Sud-de-l'Île-de-Montréal, Montreal, Canada
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Sabbatini AK, McConnell KJ, Parrish C, Frogner BK, Reddy A, Zatzick DF, Kreuter W, Basu A. Impact of a Statewide Emergency Department Information Exchange on Health Care Use and Expenditures. Health Serv Res 2022; 57:603-613. [PMID: 35235203 DOI: 10.1111/1475-6773.13963] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 02/07/2022] [Accepted: 02/18/2022] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To assess the effects of a program mandating the statewide adoption of an emergency department information exchange (EDIE) on health care utilization and spending among Medicaid enrollees in Washington state. DATA SOURCE Medicaid claims and managed care encounters from the Washington Health Care Authority. STUDY DESIGN A difference-in-differences analysis with trends was used to compare changes in ED visits, inpatient admissions, primary care visits, and expenditures among frequent ED users (≥5 ED visits in past year) to those of infrequent users through the second year Washington's program. DATA EXTRACTION The study population included adult Medicaid enrollees with ED visits between January 2010-October 2014. PRINCIPAL FINDINGS There were 505,667 ED visits among 153,543 unique enrollees included in the analysis. Washington's program was associated with a small, but statistically significant differential change of -0.70 ED visits per enrollee per year (95% CI: -1.24, -0.16) in the first year after EDIE was mandated, or 8.2% of the baseline ED visit rate among frequent users. However, by the second year of implementation, these effects on ED use were no longer significant, nor were there any measurable effects on inpatient admissions, primary care use or expenditures in any period. CONCLUSIONS Statewide implementation of EDIE was associated with a small reduction in ED use among frequent users in the first year of the program but did not change overall spending or other utilization outcomes.
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Affiliation(s)
- Amber K Sabbatini
- Magnuson Health Sciences Building, 1705 NE Pacific Street, Box 357235, Seattle, WA, United States
| | - K John McConnell
- Director of Center for Health Systems Effectiveness, Oregon Health and Sciences University, 3030 SW Moody, Portland, Oregon, United States
| | - Canada Parrish
- Department of Emergency Medicine, Section of Population Health, University of Washington, 1705 NE Pacific Street, Box 357235, Seattle, WA, United States
| | - Bianca K Frogner
- Director of Primary Care Innovation Lab, University of Washington, 4225 Roosevelt Way NE, Suite 308, Seattle, WA, United States
| | - Ashok Reddy
- Division of General Internal Medicine, University of Washington, 325 Ninth Ave, Box 359780, Seattle, WA, United States
| | | | - William Kreuter
- Research Consultant in Department of Pharmacy, University of Washington, 1959 Nebraska Pacific Street, Box 357630, Seattle, Washington, United States
| | - Anirban Basu
- Comparative Health Outcomes, Policy and Economics (CHOICE) Institute in Department of Pharmacy, University of Washington, 1959 NE Pacific Street, Box 357631 H375Q, Seattle, WA, United States
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Hudon C, Chouinard MC, Bisson M, Brousselle A, Lambert M, Danish A, Rodriguez C, Sabourin V. Case Management Programs for Improving Integrated Care for Frequent Users of Healthcare Services: An Implementation Analysis. Int J Integr Care 2022; 22:11. [PMID: 35221827 PMCID: PMC8833259 DOI: 10.5334/ijic.5652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/28/2022] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Case management programs (CMP) for frequent users of healthcare services presenting complex healthcare needs constitute an effective strategy to improve patient experience of integrated care and to decrease healthcare overuse and cost. This study sought to identify characteristics of these programs, and their implementation contexts, that help to improve patient self-management, experience of integrated care, and healthcare services use. METHODS A mixed methods multiple embedded case study design was conducted, with six CMP implemented in six hospitals of a region of Quebec (Canada). RESULTS Within-case analysis describes the structural, environmental, organizational, practitioner, patient, and innovation level characteristics of each CMP and their services integration outcomes based on patient experience, self-management and healthcare services use. Cross-case analysis suggests that the skills, leadership and experience of the case manager, providers' access to the individualized services plan, consideration of the needs of the patient and family members, their participation in decision-making, and the self-management approach, impact integrated care and healthcare services use. CONCLUSION AND DISCUSSION This study underscores the necessity of an experienced, knowledgeable and well-trained case manager with interpersonal skills to optimize CMP implementation such that patients are more proactive in their care and their outcomes improve.
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Affiliation(s)
- Catherine Hudon
- Département de médecine de famille et de médecine d’urgence, Université de Sherbrooke, 3001, 12e Avenue Nord, Sherbrooke, QC, Canada
- Centre de recherche du CHUS, 12e Avenue Nord Porte 6, Sherbrooke, QC, Canada
| | - Maud-Christine Chouinard
- Faculté des sciences infirmières, Université de Montréal, Pavillon Marguerite-d’Youville, 2375 Chemin de la Côte-Sainte-Catherine, Montreal, QC, Canada
| | - Mathieu Bisson
- Département de médecine de famille et de médecine d’urgence, Université de Sherbrooke, 3001, 12e Avenue Nord, Sherbrooke, QC, Canada
| | - Astrid Brousselle
- School of Public Administration, University of Victoria, Public Administration, HSD building, Room A302, Victoria, BC, Canada
| | - Mireille Lambert
- Centre intégré universitaire de santé et services sociaux du Saguenay–Lac-Saint-Jean, 930 rue Jacques-Cartier E, Chicoutimi, QC, Canada
| | - Alya Danish
- Département de médecine de famille et de médecine d’urgence, Université de Sherbrooke, 3001, 12e Avenue Nord, Sherbrooke, QC, Canada
| | - Charo Rodriguez
- Department of Family Medicine, McGill University, 5858, Chemin de la Côte-des-Neiges, Montreal, QC, Canada
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Case management programs for people with complex needs: Towards better engagement of community pharmacies and community-based organisations. PLoS One 2021; 16:e0260928. [PMID: 34879101 PMCID: PMC8654230 DOI: 10.1371/journal.pone.0260928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 11/19/2021] [Indexed: 11/28/2022] Open
Abstract
Introduction The objectives of this study were 1) to describe how case management programs engaged community pharmacies and community-based organisations in a perspective of integrated care for people with complex needs, and 2) to identify enablers, barriers and potential strategies for this engagement. Methods Using a descriptive qualitative design, individual interviews and focus groups with patients, healthcare providers and managers were analysed according to a mixed thematic analysis based on a deductive (Rainbow Model of Integrated Care) and an inductive approach. Results and discussion Participants highlighted the individualized service plan as a significant tool to foster a shared person-focused vision of care, information exchanges and concerted efforts. Openness to collaboration was also considered as an enabler for community stakeholders’ engagement. The lack of recognition of community-based organisations by certain providers and the time required to participate in individualized service plans were outlined as barriers to professional integration. Limited opportunities for community stakeholders to be involved in decision-making within case management programs were reported as another constraint to their engagement. Cultural differences between organisations regarding the focus of the intervention (psychosocial vs healthcare needs) and differences in bureaucratic structures and funding mechanisms may negatively affect community stakeholders’ engagement. Formal consultation mechanisms and improvement of communication channels between healthcare providers and community stakeholders were suggested as ways to overcome these barriers. Conclusion Efforts to improve care integration in case management programs should be directed toward the recognition of community stakeholders as co-producers of care and co-builders of social policies across the entire care continuum for people with complex needs.
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CLARKE LORCAN, ANDERSON MICHAEL, ANDERSON ROB, KLAUSEN MORTENBONDE, FORMAN REBECCA, KERNS JENNA, RABE ADRIAN, KRISTENSEN SØRENRUD, THEODORAKIS PAVLOS, VALDERAS JOSE, KLUGE HANS, MOSSIALOS ELIAS. Economic Aspects of Delivering Primary Care Services: An Evidence Synthesis to Inform Policy and Research Priorities. Milbank Q 2021; 99:974-1023. [PMID: 34472653 PMCID: PMC8718591 DOI: 10.1111/1468-0009.12536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Policy Points The 2018 Declaration of Astana reemphasized the importance of primary health care and its role in achieving universal health coverage. While there is a large amount of literature on the economic aspects of delivering primary care services, there is a need for more comprehensive overviews of this evidence. In this article, we offer such an overview. Evidence suggests that there are several strategies involving coverage, financing, service delivery, and governance arrangements which can, if implemented, have positive economic impacts on the delivery of primary care services. These include arrangements such as worker task-shifting and telemedicine. The implementation of any such arrangements, based on positive economic evidence, should carefully account for potential impacts on overall health care access and quality. There are many opportunities for further research, with notable gaps in evidence on the impacts of increasing primary care funding or the overall supply of primary care services. CONTEXT The 2018 Declaration of Astana reemphasized the importance of primary health care and its role in achieving universal health coverage. To strengthen primary health care, policymakers need guidance on how to allocate resources in a manner that maximizes its economic benefits. METHODS We collated and synthesized published systematic reviews of evidence on the economic aspects of different models of delivering primary care services. Building on previous efforts, we adapted existing taxonomies of primary care components to classify our results according to four categories: coverage, financing, service delivery, and governance. FINDINGS We identified and classified 109 reviews that met our inclusion criteria according to our taxonomy of primary care components: coverage, financing, service delivery, and governance arrangements. A significant body of evidence suggests that several specific primary care arrangements, such as health workers' task shifting and telemedicine, can have positive economic impacts (such as lower overall health care costs). Notably absent were reviews on the impact of increasing primary care funding or the overall supply of primary care services. CONCLUSIONS There is a great opportunity for further research to systematically examine the broader economic impacts of investing in primary care services. Despite progress over the last decade, significant evidence gaps on the economic implications of different models of primary care services remain, which could help inform the basis of future research efforts.
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Affiliation(s)
- LORCAN CLARKE
- London School of Economics and Political Science
- Trinity College Dublin
| | | | | | | | | | - JENNA KERNS
- London School of Economics and Political Science
| | | | | | | | | | - HANS KLUGE
- World Health Organization Regional Office for Europe (WHO/Europe)
| | - ELIAS MOSSIALOS
- London School of Economics and Political Science
- Imperial College London
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McBrien KA, Nguyen V, Garcia-Jorda D, Rondeau K, Polachek A, Kamran H, Lang E, Ghali W, Barnabe C, Braun T, McLane P, Milaney K, Ronksley PE, Salvalaggio G, Spackman E, Tang KL, Williamson T, Fabreau G. Connect 2 Care, a Novel Community Outreach Program for Vulnerably Housed Patients With High Acute Care Use: A Mixed-Methods Study Protocol. Front Public Health 2021; 9:605695. [PMID: 34692614 PMCID: PMC8531265 DOI: 10.3389/fpubh.2021.605695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 09/09/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Vulnerably housed individuals, especially those experiencing homelessness, have higher acute care use compared with the general population. Despite available primary care and social services, many face significant challenges accessing needed services. Connect 2 Care (C2C) is a novel transitional case management program that includes registered nurses and health navigators with complementary expertise in chronic disease management, mental health and addictions, social programs, community health, and housing, financial, transportation and legal resources. C2C bridges acute care and community services to improve care coordination. Methods and Analysis: We will perform a mixed-methods evaluation of the C2C program according to the Donabedian framework of structure, process and outcome, to understand how program structure and process, coupled with contextual factors, influence outcomes in a novel intervention. Eligible patients are homeless or unstably housed adults with complex health conditions and high acute care use. Change in emergency department visit rate 12-months after program enrolment is the primary outcome. Secondary outcomes include 12-month post-enrolment hospital admissions, cumulative hospital days, health-related quality of life, housing status, primary care attachment and substance use. Qualitative methods will explore experiences with the C2C program from multiple perspectives and an economic evaluation will assess cost-effectiveness. Discussion: Academic researchers partnered with community service providers to evaluate a novel transitional case management intervention for vulnerably housed patients with high acute-care use. The study uses mixed-methods to evaluate the Connect 2 Care program according to the Donabedian framework of structure, process and outcome, including an assessment of contextual factors that influence program success. Insights gained through this comprehensive evaluation will help refine the C2C program and inform decisions about sustainability and transferability to other settings in Canada.
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Affiliation(s)
- Kerry A McBrien
- Department of Family Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Van Nguyen
- Calgary Urban Project Society, Calgary, AB, Canada
| | | | - Kimberly Rondeau
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Alicia Polachek
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Hasham Kamran
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - William Ghali
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Cheryl Barnabe
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Ted Braun
- Alberta Health Services, Calgary, AB, Canada
| | | | - Katrina Milaney
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | | | - Eldon Spackman
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Karen L Tang
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Tyler Williamson
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Gabriel Fabreau
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Department of Medicine, University of Calgary, Calgary, AB, Canada
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Kim H, Han SJ, Lee JH, Lim J, Moon SD, Moon H, Lee SY, Yoon SW, Jung HW. A Descriptive Study of Emergency Department Visits Within 30 Days of Discharge. Ann Geriatr Med Res 2021; 25:245-251. [PMID: 34689542 PMCID: PMC8749036 DOI: 10.4235/agmr.21.0075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 10/19/2021] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Unnecessary emergency department (ED) visits are a crucial consideration in discharge planning for acutely admitted patients. This study aimed to identify the reasons for unnecessary visits to the ED within 30 days of discharge from a medical hospitalist unit. METHODS We performed a retrospective review of patients discharged in 2018 from a medical unit of tertiary teaching hospital in Korea. The authors discussed in-depth and determined whether or not an ED visit was unnecessary, and further classified the causes of unnecessary visits into three categories. RESULTS The mean age of the patients was 62.9 years (range, 15-99 years), and among the 1,343 patients discharged from the unit, 720 (53.6%) were men. Overall, 215 patients (16.0%) visited the ED within 30 days after discharge; among them, 16.3% were readmitted. Of the 215 cases of ED visits within 30 days after discharge, 57 (26.5%) were considered unnecessary. Of these, 30 (52.6%) were categorized as having failed care transition, 15 (26.3%) had unestablished care plans for predictable issues, and 12 (21.1%) had insufficient patient education. CONCLUSION A substantial number of short-term ED visits by discharged multimorbid or older medical patients were considered unnecessary. Discharging patients with a thorough discharge plan is essential to avoid unnecessary ED visits.
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Affiliation(s)
- Hyeanji Kim
- Regional Emergency Medical Center, Seoul National University Hospital, Seoul, Korea
| | - Seung Jun Han
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Hospital Medicine Center, Seoul National University Hospital, Seoul, Korea
| | - Jae Hyun Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Hospital Medicine Center, Seoul National University Hospital, Seoul, Korea
| | - Jin Lim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Hospital Medicine Center, Seoul National University Hospital, Seoul, Korea
| | - Sung do Moon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Hospital Medicine Center, Seoul National University Hospital, Seoul, Korea
| | - Hongran Moon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Hospital Medicine Center, Seoul National University Hospital, Seoul, Korea
| | - Seo-Young Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Hospital Medicine Center, Seoul National University Hospital, Seoul, Korea
| | - Sock-Won Yoon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Hospital Medicine Center, Seoul National University Hospital, Seoul, Korea
| | - Hee-Won Jung
- Division of Geriatrics, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Hellmann R, Feral-Pierssens AL, Michault A, Casalino E, Ricard-Hibon A, Adnet F, Brun-Ney D, Bouzid D, Menu A, Wargon M. The analysis of the geographical distribution of emergency departments' frequent users: a tool to prioritize public health policies? BMC Public Health 2021; 21:1689. [PMID: 34530780 PMCID: PMC8447576 DOI: 10.1186/s12889-021-11682-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 08/30/2021] [Indexed: 11/10/2022] Open
Abstract
Background The individual factors associated to Frequent Users (FUs) in Emergency Departments are well known. However, the characteristics of their geographical distribution and how territorial specificities are associated and intertwined with ED use are limited. Investigating healthcare use and territorial factors would help targeting local health policies. We aim at describing the geographical distribution of ED’s FUs within the Paris region. Methods We performed a retrospective analysis of all ED visits in the Paris region in 2015. Data were collected from the universal health insurance’s claims database. Frequent Users (FUs) were defined as having visited ≥3 times any ED of the region over the period. We assessed the FUs rate in each geographical unit (GU) and assessed correlations between FUs rate and socio-demographics and economic characteristics of GUs. We also performed a multidimensional analysis and a principal component analysis to identify a typology of territories to describe and target the FUs phenomenon. Results FUs accounted for 278,687 (11.7%) of the 2,382,802 patients who visited the ED, living in 232 GUs. In the region, median FUs rate in each GU was 11.0% [interquartile range: 9.5–12.5]. High FUs rate was correlated to the territorial markers of social deprivation. Three different categories of GU were identified with different profiles of healthcare providers densities. Conclusion FUs rate varies between territories and is correlated to territorial markers of social deprivation. Targeted public policies should focus on disadvantaged territories.
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Affiliation(s)
- Romain Hellmann
- Health Regional Agency of Ile de France, Paris, France.,Emergency Department, Bichat hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Anne-Laure Feral-Pierssens
- SAMU 93 - Emergency Department, Avicenne hospital, Assistance Publique-Hôpitaux de Paris, Bobigny, France. .,University Sorbonne Paris Nord, Health Education and Practices Laboratory (LEPS EA3412), Bobigny, France. .,CIUSSS Nord de l'île de Montréal, Québec, Montréal, Canada.
| | - Alain Michault
- Health Regional Agency of Ile de France, Paris, France.,Conservatoire National des Arts et Metiers, Paris, France
| | - Enrique Casalino
- Emergency Department, Bichat hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Paris University, INSERM, IAME, F-75006, Paris, France
| | | | - Frederic Adnet
- SAMU 93 - Emergency Department, Avicenne hospital, Assistance Publique-Hôpitaux de Paris, Bobigny, France
| | - Dominique Brun-Ney
- Direction de l'organisation médicale et des relations avec l'université, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Donia Bouzid
- Emergency Department, Bichat hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Paris University, INSERM, IAME, F-75006, Paris, France
| | - Axelle Menu
- Health Regional Agency of Ile de France, Paris, France
| | - Mathias Wargon
- Emergency Department, Centre Hospitalier de Saint-Denis, Saint-Denis, France.,Observatoire Regional des Soins Non Programmés - Ile-de-France, Saint-Denis, France
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Giannouchos TV, Kum HC, Gary J, Ohsfeldt R, Morrisey M. The Effect of the Medicaid Expansion on Frequent Emergency Department Use in New York. J Emerg Med 2021; 61:749-762. [PMID: 34518044 DOI: 10.1016/j.jemermed.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/24/2021] [Accepted: 07/03/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND There is limited evidence on the effect of the Affordable Care Act (ACA) on frequent emergency department (ED) use. OBJECTIVES To estimate the effect of the ACA Medicaid expansion on frequent ED use in New York. METHODS We used data from the Healthcare Cost and Utilization Project State Emergency Department Databases and State Inpatient Databases from 2011 to 2016. A consistent and unique patient identifier enabled us to identify ED visits by the same patient across different facilities within the state for each calendar year. Multivariate logistic regressions were used to quantify the policy's effect on frequent ED use (≥ 4 ED visits/year). We included in-state residents 18 to 64 years of age who were covered by Medicaid, private insurance, or were uninsured. Sensitivity analyses were conducted using alternative definitions of frequent use. To validate the findings, a falsification analysis was also conducted using only the 3 pre-expansion years. RESULTS Our study included 14.3 million ED patients with 23.8 million ED visits from 2011 to 2016. Frequent users (7.2%) accounted for 26.6% of all ED visits. The likelihood of frequent ED use declined by 4% among Medicaid beneficiaries (adjusted odds ratio [AOR] 0.96, 95% confidence intervals (CI) 0.95-0.97) and by 12% for the uninsured (AOR 0.88, 95% CI 0.86-0.89) in the post-expansion period, compared with the pre-expansion period. Private insurance enrollees were 9% more likely to exhibit frequent use in the post-expansion period (AOR 1.09, 95% CI 1.08-1.11). The sensitivity analyses yielded results similar to those of the main model. The falsification analyses revealed small and insignificant year-to-year changes in the 3 pre-expansion years. CONCLUSION The likelihood of frequent ED use decreased 3 years after New York implemented the ACA Medicaid expansion, particularly for Medicaid beneficiaries and the uninsured, highlighting the importance of expanding health insurance and provisions tailored at high-need populations.
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Affiliation(s)
- Theodoros V Giannouchos
- Department of Health Services Policy & Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina; Population Informatics Lab
| | - Hye-Chung Kum
- Population Informatics Lab; Department of Health Policy & Management, School of Public Health, Texas A&M University, College Station, Texas
| | - Jodie Gary
- College of Nursing, Texas A&M University, Bryan, Texas
| | - Robert Ohsfeldt
- Population Informatics Lab; Department of Health Policy & Management, School of Public Health, Texas A&M University, College Station, Texas
| | - Michael Morrisey
- Population Informatics Lab; Department of Health Policy & Management, School of Public Health, Texas A&M University, College Station, Texas
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Sathyanarayanan S, Zhou B, Maxey M. Reducing Frequency of Emergency Department and Inpatient Visits Through Focused Case Management. Prof Case Manag 2021; 26:19-26. [PMID: 33214508 DOI: 10.1097/ncm.0000000000000426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF STUDY To evaluate whether the Oklahoma State University (OSU) Health Access Network's (HAN's) case management program is effective in reducing the attendance of frequent users to the emergency department (ED) and inpatient department. PRIMARY PRACTICE SETTING This is a 2-year retrospective pre/post-case management analysis. Emergency department usage data from 2013 to 2016 of the OSU HAN contracted clinics are used in this study. This study involves case management interventions for high ED users and high-risk patients. The patients in the study must be enrolled in SoonerCare choice to be case managed. METHODOLOGY AND SAMPLE Patients who visited the ED 3 times or more in 12 months prior to their HAN enrollment and patients with 12 months of data preenrollment and postenrollment were included in the study. A historical control was used to compare ED and inpatient use per patient per month pre- and post-HAN case management. Chi-square and Wilcoxon's signed-rank tests were used to assess the data. RESULTS A total of 29 patients met the inclusion criteria. The number of ED and inpatient visits was reduced after HAN intervention (181 vs. 110, p < .001; 35 vs. 11, p < .001). The ED and inpatient use per patient per month reduced significantly from 0.52 to 0.31 (p < .001) and 0.10 to 0.03 (p < .01), respectively. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE This study suggests that continuous case management and implementation of various care plans with frequent follow-up are effective in reducing the cost of care and subsequent ED and inpatient visits.
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Affiliation(s)
- Shrieraam Sathyanarayanan
- Shrieraam Sathyanarayanan, MS, is a data analyst at the Oklahoma State University Health Access Network (OSU HAN). He manages the OSU HAN database that collects all the care management data. He has expertise in predictive modeling and machine learning
- Biting Zhou, MS, is a current PhD student in the Department of Statistics at the Oklahoma State University Sitllwater. She works on different mathematical models for sampling data
- Matthew Maxey, BSN, MAAL, RN, is the director of the Oklahoma State University (OSU) Health Access Network. He manages all the operations of the program. He designs the key components of the program, such as process improvement and quality assurance projects
| | - Biting Zhou
- Shrieraam Sathyanarayanan, MS, is a data analyst at the Oklahoma State University Health Access Network (OSU HAN). He manages the OSU HAN database that collects all the care management data. He has expertise in predictive modeling and machine learning
- Biting Zhou, MS, is a current PhD student in the Department of Statistics at the Oklahoma State University Sitllwater. She works on different mathematical models for sampling data
- Matthew Maxey, BSN, MAAL, RN, is the director of the Oklahoma State University (OSU) Health Access Network. He manages all the operations of the program. He designs the key components of the program, such as process improvement and quality assurance projects
| | - Matthew Maxey
- Shrieraam Sathyanarayanan, MS, is a data analyst at the Oklahoma State University Health Access Network (OSU HAN). He manages the OSU HAN database that collects all the care management data. He has expertise in predictive modeling and machine learning
- Biting Zhou, MS, is a current PhD student in the Department of Statistics at the Oklahoma State University Sitllwater. She works on different mathematical models for sampling data
- Matthew Maxey, BSN, MAAL, RN, is the director of the Oklahoma State University (OSU) Health Access Network. He manages all the operations of the program. He designs the key components of the program, such as process improvement and quality assurance projects
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Binnie V, Le Brocque R, Jessup M, Johnston ANB. Illustrating a novel methodology and paradigm applied to Emergency Department research. J Adv Nurs 2021; 77:4045-4054. [PMID: 34462947 DOI: 10.1111/jan.15017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 07/25/2021] [Accepted: 08/05/2021] [Indexed: 11/28/2022]
Abstract
AIM To provide a practical example of how a novel methodology and paradigm was applied to a mixed methods study exploring the healthcare experiences of Australian adults who frequently use emergency department services. DESIGN Discussion Paper. DATA SOURCES We explored published literature discussing philosophical and methodological issues related to mixed methods research. Literature searches were performed between July 2019 and February 2021. IMPLICATIONS FOR NURSING Phenomenology is a powerful methodology to explore the lived experience of research participants, but it is not without limitations. Mixed methods phenomenology allows nurse researchers to bring further clarity to their research phenomena, however, including phenomenology in mixed methods studies may be seen to be philosophically incompatible. The philosophical metaparadigm of dialectical pluralism provides nurse researchers with a new coherent methodological and philosophical framework for combining participants' descriptions of lived experience with a variety of data collection methods. It is effective when working with transdisciplinary research teams, and stakeholders representing diverse values and disciplines. CONCLUSION Complex healthcare environments require sophisticated, flexible research approaches. This paper presents mixed methods phenomenological research combined with the metaparadigm of dialectical pluralism providing a methodological framework that can support multifaceted nursing research. IMPACT The combination of mixed methods phenomenology and dialectical pluralism represents a novel solution for nurse researchers to articulate a research methodology and philosophical paradigm reflecting the complexity embedded in everyday nursing practice. This methodology offers a unique approach to exploration of challenging clinical and patient scenarios with multifaceted elements, and overcomes theories of philosophical incompatibilities between divergent methods.
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Affiliation(s)
- Vicki Binnie
- School of Nursing, Midwifery and Social Work, The University of Queensland, St Lucia, Queensland, Australia
| | - Robyne Le Brocque
- School of Nursing, Midwifery and Social Work, The University of Queensland, St Lucia, Queensland, Australia
| | - Melanie Jessup
- School of Nursing, Midwifery and Social Work, The University of Queensland, St Lucia, Queensland, Australia
| | - Amy N B Johnston
- School of Nursing, Midwifery and Social Work, The University of Queensland, St Lucia, Queensland, Australia.,Department of Emergency Medicine, Princess Alexandra Hospital, Metro South Hospital and Health Service, Brisbane, Queensland, Australia
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Predictive Model-Driven Hotspotting to Decrease Emergency Department Visits: a Randomized Controlled Trial. J Gen Intern Med 2021; 36:2563-2570. [PMID: 33694072 PMCID: PMC8390593 DOI: 10.1007/s11606-021-06664-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 02/14/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Emergency department (ED) visits contribute substantially to health care expenditures. Case management has been proposed as a strategy to address the medical and social needs of complex patients. However, strong research designs to evaluate the effectiveness of such interventions are limited. OBJECTIVES To evaluate whether a community-based case management program was associated with reduced ED utilization among complex patients. DESIGN Patients whose risk exceeded a threshold were randomly assigned to a group offered case management or to the control group. Assignment occurred at five intervals between November 2017 and January 2019. Program effectiveness for all assigned patients was assessed using an intention-to-treat effect. Program effectiveness among those who received treatment was assessed using a local average treatment effect, estimated using instrumental variables. Both estimators were adjusted for baseline characteristics using linear models. PARTICIPANTS Adults over age 18 with at least one health care encounter with Michigan Medicine or St. Joseph Mercy Health System between June 2, 2016, and November 27, 2018. INTERVENTIONS Intervention arm participants (n = 486) were offered coordinated case management across medical, mental health, and social service organizations. Control arm participants (n = 409) received usual care. MAIN MEASURES The primary outcome was the number of ED visits in the 6 months following randomization into the study. Secondary outcomes were 6-month counts of inpatient and outpatient visits. KEY RESULTS Of the 486 patients assigned to the intervention, 131 (27%) consented to receive case management. The intention-to-treat effect on ED visits was + 0.14 (95% CI: - 0.27 to + 0.55). The local average treatment effect among those who consented and received case management was + 0.53 (95% CI: - 1.00 to + 2.05). Intention-to-treat and local average treatment effects were not significant for secondary outcomes. CONCLUSIONS The community case management intervention targeting ED visits was not associated with reduced utilization. Future case management interventions may benefit from additional patient engagement strategies and longer evaluation time periods. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT03293160.
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Kaltsidis G, Bamvita JM, Grenier G, Fleury MJ. Predictors of Frequent Emergency Department Utilization for Mental Health Reasons. J Behav Health Serv Res 2021; 48:259-273. [PMID: 32185614 DOI: 10.1007/s11414-020-09695-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Overcrowding in emergency departments (ED) jeopardizes quality and access to health care, which represents a major issue for service delivery. This study determined predictors of frequent ED utilization among 320 patients recruited from six hospital ED in Quebec (Canada). Data collection included patient interviews and administrative databanks. A hierarchical linear regression analysis was performed using the Andersen Behavioral Model as a framework, with variables organized into predisposing, enabling, and needs factors. Results showed that needs factors were most strongly associated with ED utilization, particularly schizophrenia and personality disorders. Predisposing and enabling factors each contributed one variable to the model: past hospitalization for Mental Health (MH) reasons, and having regular care from an outpatient psychiatrist over the 12 months prior to interview at the ED, respectively. Increasing integration of MH services in networks may reduce unnecessary ED utilization and overcrowding, while providing better accessibility and care continuity for patients who visit ED for MH reasons.
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Affiliation(s)
- Gesthika Kaltsidis
- Department of Psychiatry, McGill University, Montreal, QC, Canada.,Douglas Mental Health University Institute Research Centre, Montreal, QC, Canada
| | - Jean-Marie Bamvita
- Douglas Mental Health University Institute Research Centre, Montreal, QC, Canada
| | - Guy Grenier
- Douglas Mental Health University Institute Research Centre, Montreal, QC, Canada
| | - Marie-Josée Fleury
- Department of Psychiatry, McGill University, Montreal, QC, Canada. .,Douglas Mental Health University Institute Research Centre, Montreal, QC, Canada.
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Estrella A, Scheidell J, Khan M, Castelblanco D, Mijanovich T, Lee DC, Gelberg L, Doran KM. Cross-sectional Analysis of Food Insecurity and Frequent Emergency Department Use. West J Emerg Med 2021; 22:911-918. [PMID: 35354018 PMCID: PMC8328160 DOI: 10.5811/westjem.2021.3.50981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 03/08/2021] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Emergency department (ED) patients have higher than average levels of food insecurity. We examined the association between multiple measures of food insecurity and frequent ED use in a random sample of ED patients. METHODS We completed survey questionnaires with randomly sampled adult patients from an urban public hospital ED (n = 2,312). We assessed food insecurity using four questions from the United States Department of Agriculture Household Food Security Survey. The primary independent variable was any food insecurity, defined as an affirmative response to any of the four items. Frequent ED use was defined as self-report of ≥4 ED visits in the past year. We examined the relationship between patient food insecurity and frequent ED use using bivariate and multivariable analyses and examined possible mediation by anxiety/depression and overall health status. RESULTS One-third (30.9%) of study participants reported frequent ED use, and half (50.8%) reported any food insecurity. Prevalence of food insecurity was higher among frequent vs. non-frequent ED users, 62.8% vs 45.4% (P <0.001). After controlling for potential confounders, food insecurity remained significantly associated with frequent ED use (adjusted odds ratio 1.48, 95% confidence interval, 1.20-1.83). This observed association was partially attenuated when anxiety/depression and overall health status were added to models. CONCLUSION The high observed prevalence of food insecurity suggests that efforts to improve care of ED patients should assess and address this need. Further research is needed to assess whether addressing food insecurity may play an important role in efforts to reduce frequent ED use for some patients.
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Affiliation(s)
- Alex Estrella
- UMMS-Baystate, Department of Emergency Medicine, Springfield, Massachusetts
| | - Joy Scheidell
- New York University School of Medicine, NYU Langone Health, Department of Population Health, New York, New York
| | - Maria Khan
- New York University School of Medicine, NYU Langone Health, Department of Population Health, New York, New York
| | - Donna Castelblanco
- New York City Department of Health and Mental Hygiene, New York, New York
| | - Tod Mijanovich
- New York University Steinhardt School of Culture, Education, and Human Development, Department of Applied Statistics, Social Science, and Humanities, New York, New York
| | - David C Lee
- New York University School of Medicine, Departments of Emergency Medicine and Population Health, New York, New York
| | - Lillian Gelberg
- David Geffen School of Medicine at UCLA, Department of Family Medicine, Los Angeles, California.,UCLA Fielding School of Public Health, Department of Health Policy and Management, Los Angeles, California.,VA Greater Los Angeles Healthcare System, Office of Healthcare Transformation and Innovation, Los Angeles, California
| | - Kelly M Doran
- New York University School of Medicine, Departments of Emergency Medicine and Population Health, New York, New York
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Andriotti T, Dalton MK, Jarman MP, Lipsitz S, Chaudhary MA, Tilley L, Learn PA, Schoenfeld AJ, Goralnick E. Super-Utilization of the Emergency Department in a Universally Insured Population. Mil Med 2021; 186:e819-e825. [PMID: 33247301 DOI: 10.1093/milmed/usaa399] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/23/2020] [Accepted: 09/21/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Super-utilizers (patients with 4 or more emergency department [ED] visits a year) account for 10% to 26% of all ED visits and are responsible for a growing proportion of healthcare expenditures. Patients recognize the ED as a reliable provider of acute care, as well as a timely resource for diagnosis and treatment. The value of ED care is indisputable in critical and emergent conditions, but in the case of non-urgent conditions, ED utilization may represent an inefficiency in the healthcare system. We sought to identify patient and clinical characteristics associated with ED super-utilization in a universally insured population. MATERIAL AND METHODS We performed a retrospective cohort study using TRICARE claims data from the Military Health System Data Repository (2011-2015). We reviewed the claims data of all adult patients (aged 18-64 years) who had at least one encounter at the ED for any cause. Multivariable logistic regression was used to determine independent factors associated with ED super-utilization. RESULTS Factors associated with increased odds of ED super-utilization included Charlson Score ≥2 (adjusted odds ratio [aOR] 1.98, 95% confidence interval [CI]: 1.90-2.06), being eligible for Medicare (aOR 1.95, 95% CI: 1.90-2.01), and female sex (aOR 1.35, 95% CI: 1.33-1.37). Active duty service members (aOR 0.69, 95% CI 0.68-0.72) and beneficiaries with higher sponsor-rank (Officers: aOR 0.50, 95% CI: 0.55-0.57; Senior enlisted: aOR 0.82, 95% CI: 0.81-0.83) had lower odds of ED super-utilization. The most common primary diagnoses for ED visits among super-utilizers were abdominal pain, headache and migraine, chest pain, urinary tract infection, nausea and vomiting, and low back pain. CONCLUSIONS Risk of ED super-utilization appears to increase with age and diminished health status. Patient demographic and clinical characteristics of ED super-utilization identified in this study can be used to formulate healthcare policies addressing gaps in primary care in diagnoses associated with ED super-utilization and develop interventions to address modifiable risk factors of ED utilization.
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Affiliation(s)
- Tomas Andriotti
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Michael K Dalton
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Molly P Jarman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Stuart Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Muhammad Ali Chaudhary
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Laura Tilley
- Department of Surgery, Uniformed Services University, Bethesda, MD, USA
| | - Peter A Learn
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, MD, USA
| | - Andrew J Schoenfeld
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Eric Goralnick
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Typology of Currently or Formerly Homeless Individuals Based on Their Use of Health and Social Services. Community Ment Health J 2021; 57:948-959. [PMID: 32734310 DOI: 10.1007/s10597-020-00693-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 07/18/2020] [Indexed: 10/23/2022]
Abstract
This study identified profiles among 455 currently or formerly homeless individuals in Quebec (Canada), based on health and social service use. Using latent class analysis, four profiles were identified that grouped individuals with: (1) few health problems, and using few case managers and family doctors, but with high frequency of psychiatric consultations, emergency department (ED) visits and hospitalizations; (2) chronic physical illnesses, having case managers and family doctors, but low frequency of ED visits and hospitalizations; (3) moderate health problems and little service use; and (4) multiple and complex health problems and high frequency of service use. These profiles suggest the following recommendations to more adequately meet patient needs: regarding Class 1, improved outreach services, more ED liaison nurses and peer navigation; Class 2: more family doctors and case managers; Class 3: higher family doctors; and Class 4: more assertive or intensive case management, harm reduction and permanent housing resources.
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Werner BC, Bustos FP, Gean RP, Deasey MJ. Emergency Department Visits in the Year Prior to Total Shoulder Arthroplasty as a Risk Factor for Postoperative Emergency Department Visits. HSS J 2021; 17:200-206. [PMID: 34421431 PMCID: PMC8361596 DOI: 10.1177/1556331621995775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/04/2020] [Indexed: 11/17/2022]
Abstract
Background: Recent research has found a high rate of emergency department (ED) use after lower extremity arthroplasty; one study found a risk factor for ED presentation after lower extremity arthroplasty was presentation to the ED in the year prior to surgery. It is not known whether a similar association exists for total shoulder arthroplasty (TSA). Questions/Purposes: The goal of this study was to investigate the relationship between preoperative ED visits and postoperative ED visits after anatomic TSA. Methods: The 100% Medicare database was queried for patients who underwent anatomic TSA from 2005 to 2014. Emergency department visits within the year prior to the date of TSA were identified. Patients were additionally stratified by the number and timing of preoperative ED visits. The primary outcome measure was one or more postoperative ED visits within 90 days. A multivariate logistic regression analysis was used to control for patient demographics and comorbidities. Results: Of the 144,338 patients identified, 32,948 (22.8%) had an ED visit in the year prior to surgery. Patients with at least 1 ED visit in the year before surgery presented to the ED at a significantly higher rate than patients without preoperative ED visits (16% versus 6%). An ED visit in the year prior to TSA was the most significant risk factor for postoperative ED visits (in the multivariate analysis). The number of preoperative ED visits in the year prior to surgery demonstrated a significant dose-response relationship with increasing risk of postoperative ED visits. Conclusions: Postoperative ED visits occurred in nearly 10% of Medicare patients who underwent TSA in the period studied. More frequent presentation to the ED in the year prior to anatomic TSA was associated with increasing risk of postoperative ED visits. Future studies are needed to investigate the reasons for preoperative ED visits and if any modifiable risk factors are present to improve the ability to risk stratify and optimize patients for elective TSA.
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Affiliation(s)
- Brian C. Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, VA, USA
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Brunner L, Canepa Allen M, Malebranche M, Hudon C, Senn N, Hugli O, Vu F, Akré C, Bodenmann P. Qualitative evaluation of primary care providers' experiences caring for frequent users of the emergency department. BMJ Open 2021; 11:e044326. [PMID: 34172545 PMCID: PMC8237725 DOI: 10.1136/bmjopen-2020-044326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES Many interventions have been developed over the years to offer frequent users of the emergency department (FUEDs) better access to quality coordinated healthcare. Despite recognising the role primary care physicians (PCPs) play in FUEDs' care, to date their perceptions of case management, the most studied intervention, have rarely been assessed. Furthermore, a gap regarding PCPs' experience of caring for FUEDs persists. Thus, this study aimed to explore PCPs' perceptions of the care provided to FUEDs in emergency and primary care settings, their views on the local case management team (CMT), and their suggestions to improve FUEDs' care. DESIGN Qualitative study using in-depth semistructured interviews and inductive thematic analysis. SETTING Canton of Vaud, Switzerland. PARTICIPANTS Thirty PCPs participated, 16 in private practice (PP-PCPs) and 14 based at the Lausanne University Centre of General Medicine and Public Health (Unisanté-U-PCPs). RESULTS U-PCPs and PP-PCPs thought that most FUEDs' emergency department (ED) visits were legitimate, but questioned ED adequacy to meet FUEDs' needs. Yet, both PCP groups reported encountering many challenges in FUEDs' care themselves. In this context, PP-PCPs seemed more satisfied of the care they provided to FUEDs than U-PCPs. Generally, U-PCPs seemed to find more value in the CMT to help them care for FUEDs than PP-PCPs. To enhance FUEDs' care, U-PCPs and PP-PCPs suggested enhancing collaboration with other healthcare providers. U-PCPs also wished to increase their availability, and some PP-PCPs considered outpatient clinics, larger group practices or medical centres most appropriate to handle FUEDs' needs. CONCLUSIONS This study highlights the many challenges PCPs face in caring for FUEDs, that a CM intervention has the potential to mitigate, and provides ways forward in improving FUEDs' care, including reinforced communication with the CMT and ED physicians, and structural changes to their own way of delivering care to FUEDs.
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Affiliation(s)
- Laureline Brunner
- Department of Vulnerabilities and Social Medicine, Unisanté, Lausanne, Vaud, Switzerland
| | - Marina Canepa Allen
- Department of Vulnerabilities and Social Medicine, Unisanté, Lausanne, Vaud, Switzerland
| | - Mary Malebranche
- Department of Medicine, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada
| | - Catherine Hudon
- Family Medicine and Emergency Medicine Department, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Nicolas Senn
- Department of Family Medicine, Unisanté, Lausanne, Vaud, Switzerland
| | - Olivier Hugli
- Emergency Department, University Hospital of Lausanne, Lausanne, Vaud, Switzerland
| | - Francis Vu
- Department of Vulnerabilities and Social Medicine, Unisanté, Lausanne, Vaud, Switzerland
| | - Christina Akré
- Department of Epidemiology and Health Systems-University of Lausanne, Unisanté, Lausanne, Vaud, Switzerland
| | - Patrick Bodenmann
- Department of Vulnerabilities and Social Medicine, Unisanté, Lausanne, Vaud, Switzerland
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Braz PGDCG, Vila VDSC, Neves HCC. Strategies for case management in transitional care in emergency services: scoping review. Rev Bras Enferm 2021; 73Suppl 5:e20190506. [PMID: 33027493 DOI: 10.1590/0034-7167-2019-0506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 06/14/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to map and synthesize the strategies implemented for case management in transitional care for patients with complex needs in emergency services. METHOD a scoping review conducted under the Joanna Briggs Institute guidance. Twenty-three studies were analyzed, with different methodological designs, on the strategies used in case management involving adult and elderly populations in emergency services. RESULTS the main strategies employed were patient risk stratification screening/identification, care management plan, coordination of care through multidisciplinary activities, support for the transition process, continuous patient monitoring, and follow-up. FINAL CONSIDERATIONS these strategies used structured approaches to care in emergency services to promote support for self-management and effective transitional care for people with complex needs, ensuring comprehensiveness, coordination, and continuity of care.
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Moledina A, Magwood O, Agbata E, Hung J, Saad A, Thavorn K, Pottie K. A comprehensive review of prioritised interventions to improve the health and wellbeing of persons with lived experience of homelessness. CAMPBELL SYSTEMATIC REVIEWS 2021; 17:e1154. [PMID: 37131928 PMCID: PMC8356292 DOI: 10.1002/cl2.1154] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background Homelessness has emerged as a public health priority, with growing numbers of vulnerable populations despite advances in social welfare. In February 2020, the United Nations passed a historic resolution, identifying the need to adopt social-protection systems and ensure access to safe and affordable housing for all. The establishment of housing stability is a critical outcome that intersects with other social inequities. Prior research has shown that in comparison to the general population, people experiencing homelessness have higher rates of infectious diseases, chronic illnesses, and mental-health disorders, along with disproportionately poorer outcomes. Hence, there is an urgent need to identify effective interventions to improve the lives of people living with homelessness. Objectives The objective of this systematic review is to identify, appraise, and synthesise the best available evidence on the benefits and cost-effectiveness of interventions to improve the health and social outcomes of people experiencing homelessness. Search Methods In consultation with an information scientist, we searched nine bibliographic databases, including Medline, EMBASE, and Cochrane CENTRAL, from database inception to February 10, 2020 using keywords and MeSH terms. We conducted a focused grey literature search and consulted experts for additional studies. Selection Criteria Teams of two reviewers independently screened studies against our inclusion criteria. We included randomised control trials (RCTs) and quasi-experimental studies conducted among populations experiencing homelessness in high-income countries. Eligible interventions included permanent supportive housing (PSH), income assistance, standard case management (SCM), peer support, mental health interventions such as assertive community treatment (ACT), intensive case management (ICM), critical time intervention (CTI) and injectable antipsychotics, and substance-use interventions, including supervised consumption facilities (SCFs), managed alcohol programmes and opioid agonist therapy. Outcomes of interest were housing stability, mental health, quality of life, substance use, hospitalisations, employment and income. Data Collection and Analysis Teams of two reviewers extracted data in duplicate and independently. We assessed risk of bias using the Cochrane Risk of Bias tool. We performed our statistical analyses using RevMan 5.3. For dichotomous data, we used odds ratios and risk ratios with 95% confidence intervals. For continuous data, we used the mean difference (MD) with a 95% CI if the outcomes were measured in the same way between trials. We used the standardised mean difference with a 95% CI to combine trials that measured the same outcome but used different methods of measurement. Whenever possible, we pooled effect estimates using a random-effects model. Main Results The search resulted in 15,889 citations. We included 86 studies (128 citations) that examined the effectiveness and/or cost-effectiveness of interventions for people with lived experience of homelessness. Studies were conducted in the United States (73), Canada (8), United Kingdom (2), the Netherlands (2) and Australia (1). The studies were of low to moderate certainty, with several concerns regarding the risk of bias. PSH was found to have significant benefits on housing stability as compared to usual care. These benefits impacted both high- and moderate-needs populations with significant cimorbid mental illness and substance-use disorders. PSH may also reduce emergency department visits and days spent hospitalised. Most studies found no significant benefit of PSH on mental-health or substance-use outcomes. The effect on quality of life was also mixed and unclear. In one study, PSH resulted in lower odds of obtaining employment. The effect on income showed no significant differences. Income assistance appeared to have some benefits in improving housing stability, particularly in the form of rental subsidies. Although short-term improvement in depression and perceived stress levels were reported, no evidence of the long-term effect on mental health measures was found. No consistent impact on the outcomes of quality of life, substance use, hospitalisations, employment status, or earned income could be detected when compared with usual services. SCM interventions may have a small beneficial effect on housing stability, though results were mixed. Results for peer support interventions were also mixed, though no benefit was noted in housing stability specifically. Mental health interventions (ICM, ACT, CTI) appeared to reduce the number of days homeless and had varied effects on psychiatric symptoms, quality of life, and substance use over time. Cost analyses of PSH interventions reported mixed results. Seven studies showed that PSH interventions were associated with increased cost to payers and that the cost of the interventions were only partially offset by savings in medical- and social-services costs. Six studies revealed that PSH interventions saved the payers money. Two studies focused on the cost-effectiveness of income-assistance interventions. For each additional day housed, clients who received income assistance incurred additional costs of US$45 (95% CI, -$19, -$108) from the societal perspective. In addition, the benefits gained from temporary financial assistance were found to outweigh the costs, with a net savings of US$20,548. The economic implications of case management interventions (SCM, ICM, ACT, CTI) was highly uncertain. SCM clients were found to incur higher costs than those receiving the usual care. For ICM, all included studies suggested that the intervention may be cost-offset or cost-effective. Regarding ACT, included studies consistently revealed that ACT saved payers money and improved health outcomes than usual care. Despite having comparable costs (US$52,574 vs. US$51,749), CTI led to greater nonhomeless nights (508 vs. 450 nights) compared to usual services. Authors' Conclusions PSH interventions improved housing stability for people living with homelessness. High-intensity case management and income-assistance interventions may also benefit housing stability. The majority of included interventions inconsistently detected benefits for mental health, quality of life, substance use, employment and income. These results have important implications for public health, social policy, and community programme implementation. The COVID-19 pandemic has highlighted the urgent need to tackle systemic inequality and address social determinants of health. Our review provides timely evidence on PSH, income assistance, and mental health interventions as a means of improving housing stability. PSH has major cost and policy implications and this approach could play a key role in ending homelessness. Evidence-based reviews like this one can guide practice and outcome research and contribute to advancing international networks committed to solving homelessness.
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Affiliation(s)
| | - Olivia Magwood
- C.T. Lamont Primary Health Care Research CentreBruyere Research InstituteOttawaCanada
| | - Eric Agbata
- Bruyere Research Institute, School of EpidemiologyPublic Health and Preventive MedicineOttawaCanada
| | - Jui‐Hsia Hung
- Faculty of Medicine, School of Epidemiology and Public HealthUniversity of OttawaOttawaCanada
| | - Ammar Saad
- Department of Epidemiology, C.T. Lamont Primary Care Research Centre, Bruyere Research InstituteUniversity of OttawaOttawaCanada
| | - Kednapa Thavorn
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaCanada
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Carpenter LJ, Bautovich A, Sharma S, Gatsi M, Wand APF. The development of pathways for responding to patient complexity in a liaison psychiatry setting. Australas Psychiatry 2021; 29:256-260. [PMID: 32640835 DOI: 10.1177/1039856220937648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The aims were to develop and operationalise a method of identifying patients at increased risk of adverse outcomes due to clinical and systems complexity within consultation-liaison psychiatry (CLP), and to formalise escalation processes for enhanced input with targeted clinical and organisational support. METHODS The literature pertaining to methods for identifying and responding to complexity in general hospital settings was reviewed. An Escalation Tool operationalising the identification of complexity and response pathways was devised and tested. Feedback on the face validity and utility guided refinement. RESULTS Two established tools that assess complexity, INTERMED and the Patient-Centred Accreditation method (PCAM) and a novel 'episode complexity' screening method, were identified and informed the development of a tool for identifying and responding to complexity, which was then piloted. The tool was deemed useful, notwithstanding variability in scoring. CONCLUSIONS The Escalation Tool combined elements of existing measures to identify complexity in general hospital inpatients and guide pathways for action. It was well received and considered feasible for implementation, with local adaptation according to available resources.
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Affiliation(s)
| | - Alison Bautovich
- Department of Consultation-Liaison Psychiatry, Prince of Wales Hospital, Australia.,School of Psychiatry, University of New South Wales, Australia
| | - Swapnil Sharma
- Department of Consultation-Liaison Psychiatry, Prince of Wales Hospital, Australia.,School of Psychiatry, University of New South Wales, Australia
| | - Mike Gatsi
- Eastern Suburbs Mental Health, Australia
| | - Anne Pamela Frances Wand
- Department of Consultation-Liaison Psychiatry, Prince of Wales Hospital, Australia.,School of Psychiatry, University of New South Wales, Australia
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Franco A, Meldrum J, Ngaruiya C. Identifying homeless population needs in the Emergency Department using Community-Based Participatory Research. BMC Health Serv Res 2021; 21:428. [PMID: 33952265 PMCID: PMC8097852 DOI: 10.1186/s12913-021-06426-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 04/21/2021] [Indexed: 11/10/2022] Open
Abstract
Background Annually 1.5 million Americans face housing insecurity, and compared to their domiciled counterparts are three times more likely to utilize the Emergency Department (ED). Community Based Participatory Research (CBPR) methods have been employed in underserved populations, but use in the ED has been limited. We employed CBPR in an urban American hospital with a primary goal of improved linkage to care, reduced ED recidivism, and improved homeless health care. Methods A needs analysis was performed using semi-structured individual interviews with participants experiencing homelessness as well as with stakeholders. Results were analyzed using principles of grounded theory. At the end of the interviews, respondents were invited to join the “CBPR team”. At CBPR team meetings, results from interviews were expounded upon and discussions on intervention development were conducted. Results Twenty-five stakeholders were interviewed including people experiencing housing insecurity, ED staff, inpatient staff, and community shelters and services. Three themes emerged from the interviews. First, the homeless population lack access to basic needs, thus management of medical needs must be managed alongside social ones. Second, specific challenges to address homeless needs in the ED include episodic care, inability to recognize housing insecurity, timely involvement of ancillary staff, and provider attitudes towards homeless patients affecting quality of care. Lastly, improved discharge planning and communication with outside resources is essential to improving homeless health and decreasing ED overutilization. A limitation of results is difficulty for participants experiencing homelessness to commit to regular CBPR meetings, as well as possible bias towards social networks influencing included stakeholders. Conclusion CBPR is a promising approach to address gaps in homeless health care as it provides a comprehensive view incorporating various critical perspectives. Key ED-based interventions addressing recidivism include improved identification of housing insecurity, reinforced relationships between ED and community resources, and better discharge planning.
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Affiliation(s)
- Andrew Franco
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA.
| | - Jonathan Meldrum
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Christine Ngaruiya
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
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