Evaluation of a Multidisciplinary Care Coordination Program for Frequent Users of the Emergency Department

Interventions to Reduce Repeat Presentations to Hospital Emergency Departments for Mental Health Concerns: A Scoping Review of the Literature

BACKGROUND

The number of readmissions to the emergency department (ED) for mental health services each year is significant, which increases healthcare costs and negatively affects the morale and quality of life of patients and their families.

OBJECT

This scoping review aimed to establish a better understanding of interventions that have been implemented to reduce psychiatric patient readmission and ED use within the ED, to identify areas for improvement, and therefore to assist in the development of more effective actions in the future.

METHOD

The scoping review was conducted on several bibliographic databases to identify relevant studies. Two researchers independently screened and reviewed titles, abstracts, and full-text articles that met the inclusion criteria. Using Covidence software, 26 out of 6951 studies were eligible for inclusion in this scoping review based on the PRISMA checklist. Data were extracted, collated, summarized, presented, and discussed.

RESULT

This review identified 26 studies which examined interventions aimed to reduce ED visits, such as the High Alert Program (HAP), the Patient-Centered Medical Home (PCMH), the Primary Behavioral Health Care Integration (PBHCI), and the Collaborative Care (CC) Program, etc. Twenty-three of the studies were conducted in North America, while the rest were conducted in Europe and Australia. A total of 16 studies examined interventions directed to any mental health conditions, while the rest addressed specific health conditions, such as substance use disorders, schizophrenia, anxiety, depression. Interventions involved comprehensive and multidisciplinary services, incorporation of evidence-based behavioral and pharmacological strategies, and emphasized the case management that was found to be effective. Additionally, there was a marked consideration for diverse mental health groups, such as those with substance use disorder and of young age. Most interventions showed a positive effect on reducing psychiatric ED visits.

CONCLUSION

Various initiatives have been implemented worldwide to reduce the number of emergency department visits and the associated burden on healthcare systems. This review highlights the greater need for developing more accessible interventions, as well as setting up a comprehensive community health care system aiming to reduce frequent ED presentations.

Evaluation of the use of individualized patient care plans in frequent emergency department visitors with pain complaints

Background

Pain is one of the most common complaints that patients present to the emergency department for; emergency medicine providers are tasked with providing appropriate pain relief while simultaneously limiting the risk of personal and societal harm that may result from opioid misuse. The Lakeland Regional Medical Center developed a medical management program that identified frequent emergency department visitors with a chief complaint of pain. Individualized care plans were developed for these patients. A retrospective review was then conducted to assess the efficacy of these care plans in reducing the number of emergency department visits for pain-related complaints by the patients entered into the medical management program.

Results

There were 294 patients; 65% were male, and the median age was 41 (interquartile range: 33 to 51). A total of 80% percent of the patients were white, and the payors were as follows: 53% were self-pay, 42% were government programs, and 5% had private insurance. The three most common chronic pain complaints were 39% abdominal pain, 24% back/neck pain, and 23% headache/migraine (patients could have more than one area of pain). A total of 60% of the patients had a primary care provider, and another 18% had a pain management provider in addition to primary care.

Post plan admissions were significantly reduced to a median of 1 (IQR 0 to 3) with the Wilcoxon signed-rank test’s p-value of less than 0.001.

Conclusion

The authors describe their experience with a quality improvement initiative that identifies frequent emergency department visitors with a chief complaint of pain and provides individualized care plans to these patients. The goals of the program are to improve patient’s quality and consistency of care, through interventions that eliminate the prescribing of opioids while providing non-opioid alternatives.

Cost and Cost Savings of Navigation Services to Avoid Rehospitalization for a Comorbid Substance Use Disorder Population

BACKGROUND

A randomized clinical trial found that patient navigation for hospital patients with comorbid substance use disorders (SUDs) reduced emergency department (ED) and inpatient hospital utilization compared with treatment-as-usual.

OBJECTIVE

To compare the cost and calculate any cost savings from the Navigation Services to Avoid Rehospitalization (NavSTAR) intervention over treatment-as-usual.

RESEARCH DESIGN

This study calculates activity-based costs from the health care providers and uses a net benefits approach to calculate the cost savings generated from NavSTAR. NavSTAR provided patient navigation focused on engagement in SUD treatment, starting before hospital discharge and continuing for up to 3 months postdischarge.

SUBJECTS

Adult hospitalized medical/surgical patients with comorbid SUD for opioids, cocaine, and/or alcohol.

COST MEASURES

Cost of the 3-month NavSTAR patient navigation intervention and the cost of all inpatient days and ED visits over a 12-month period.

RESULTS OF BASE CASE ANALYSIS

NavSTAR generated $17,780 per participant in cost savings. Ninety-seven percent of bootstrapped samples generated positive cost savings, and our sensitivity analyses did not change our results.

LIMITATIONS

Participants were recruited at one hospital in Baltimore, MD through the hospital's addiction consultation service. Findings may not generalize to the broader population. Outpatient health care cost data was not available through administrative records.

CONCLUSION

Our findings show that patient navigation interventions should be considered by payors and policy makers to reduce the high hospital costs associated with comorbid SUD patients.

Challenges in inpatient care coordinators’ clinical workflow and opportunities in designing a health IT solution: A mixed methods study

Introduction

Inpatient care coordinators (ICCs) in the United States play a critical role in case management and care transition. ICCs spend a large amount of time in chart review and documentation through electronic health record (EHR) systems. However, significant knowledge gaps exist regarding their workflow barriers and their use of health information technology (Health IT). Using only quantitative or quantitative methods does not provide a comprehensive picture about ICC’s workflow due to its complex and dynamic nature. This work aimed to address this gap by conducting a mixed-methods study to understand the workflow of ICCs and identifying challenges in care deliver and documentation activities.

Methods

The study adopted a concurrent triangulation design including qualitative interviews with 12 ICC staff members in the United States followed by extraction of their EHR event logs for one month. The qualitative interview data were analyzed thematically, and the log data were analyzed statistically. The results were triangulated and interpreted.

Results

Three major workflow barriers faced by ICCs were identified: long travel time, heavy documentation load, and suboptimal communication. The event logs provided empirical evidence to support the workflow barriers identified in the interviews, especially in travel time and documentation load.

Discussion

ICC workflow has several inefficiencies. The study generated four design considerations to develop a Health IT solution: Mobility, EHR integration, Team-based Communication, and User Adoption to improve workflow efficiency and care coordination. Using a mixed-methods approach is effective and efficient in collecting and analyzing clinical workflow.

Multidisciplinary Firms and the Treatment of Chronic Pain: A Case Study of Low Back Pain

Sixteen million people suffer with chronic low back pain and related healthcare expenditures can be as high as $USD 635 billion. Current pain treatments help a significant number of acute pain patients, allowing them to obtain various treatments and then “exit the market for pain services” quickly. However, chronic patients remain in pain and need multiple, varying treatments over time. Often, a single pain provider does not oversee their care. Here, we analyze the current pain market and suggest ways to establish a new treatment paradigm. We posit that more cost effective treatment and better pain relief can be achieved with multi-disciplinary care with a provider team overseeing care.

Does Neuromodulation Reduce Chronic Pain Patient Emergency Department Utilization?

BACKGROUND

Chronic pain (CP) affects roughly 100 million adults in the United States. These subjects present disproportionately to the emergency department (ED). Neuromodulation (NM) has been shown to reduce ED visits longitudinally in subjects.

OBJECTIVE

To compare ED utilization rates between subjects with CP with and without NM.

METHODS

Subjects with failed back surgery syndrome, complex regional pain syndrome, or neuropathic pain diagnosis who visited the hospital between January 1, 2019, and December 31, 2019, were included. Subjects were divided into a NM-treated cohort and a non-NM cohort. Demographic information, medications, and pain provider visits were obtained. Pain-related ED visits between 2017 and 2019 were compared.

RESULTS

A total of 2516 subjects were identified; 291 (11.6%) previously underwent NM. The non-NM cohort had significantly higher rate of pain-related ED visits compared with the NM cohort (15.1% vs 10.0%, P = .018). Younger age (odds ratio [OR] = 0.888 [0.843-0.935]), shorter distance to the hospital (OR = 0.807 [0.767-0.849]), lower household income (OR = 0.865 [0.831-0.901]), opioid use (OR = 1.375 [1.291-1.465]), nonopioid use (OR = 1.079 [1.033-1.128]), and non-NM therapy (OR = 1.751 [1.283-2.390]) were significant predictors of ED visits. Opioid use was the only significant predictor (OR = 6.124 [1.417-26.473]) associated with ED visits in the NM cohort.

CONCLUSION

Subjects who underwent NM had fewer visits to the ED when compared with similar subjects who received conventional treatment. Opioid use prompted increased ED utilization in both cohorts. We posit that NM leads to improvement in pain outcomes, integration with multidisciplinary pain specialists, and reduction in severity and frequency of acute pain exacerbations, thereby limiting health care resource utilization.

Reducing Frequency of Emergency Department and Inpatient Visits Through Focused Case Management

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.

Illustrating a novel methodology and paradigm applied to Emergency Department research

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.

Experience of emergency department use among persons with a history of adverse childhood experiences

BACKGROUND

Adverse childhood experiences (ACEs) are associated with increased morbidity and mortality, lower levels of distress tolerance, and greater emotional dysregulation, as well as with increased healthcare utilization. All these factors may lead to an increased use of emergency department (ED) services. Understanding the experience of ED utilization among a group of ED users with high ACE scores, as well as their experiences as viewed through the lens of a trauma and violence informed care (TVIC) framework, could be important to their provision of care.

METHODS

This is the qualitative portion of a larger mixed methods study. Twenty-five ED users with high ACE scores completed in depth interviews. Thematic analysis of the interview transcripts was undertaken and directed content analysis was used to examine the transcripts against a TVIC framework.

RESULTS

The majority of participants experienced excellent care although challenges to this experience were faced by many in the areas of registration and triage. Some participants did identify negative experiences of care and stigma when presenting with mental health conditions and pain crises, as did participants who perceived that they were considered "different" (dressed differently, living in poverty, young parents, etc.). Participants were thoughtful about their reasons for seeking ED care including lack of timely access to their family doctor, perceived urgency of their condition, or needs that fell outside the scope of primary care. Participants' experiences mapped onto a TVIC framework such that their needs and experiences could be framed using a TVIC lens.

CONCLUSIONS

While the ED care experience was excellent for most participants, even those with a trauma history, there existed a subset of vulnerable patients for whom the principles of TVIC were not met, and for whom implementation of trauma informed care might have a positive impact on the overall experience of care. Recommendations include training around TVIC for ED leadership, staff and physicians, improved access to semi-urgent primary care, ED patient care plans integrating TVIC principles, and improved support for triage nurses and registration personnel.