Patient-Centered Tips to Cut Emergency Department Overutilization

Leaning on low-acuity care settings

The first issue of ED overutilization, that patients are accessing the department for non-emergent care, can be addressed by creating access to low-acuity care settings. The primary care clinic can be one of these settings, but other low-cost and convenient facilities have cropped up to fill this gap, too.

Perhaps most notably, retail and urgent care clinics have emerged as key alternatives to the emergency department. Patients can visit retail and urgent care clinics on a walk-in basis across their communities.

In the case of retail clinics, these facilities are extremely cost-effective and offer a wide variety of common services. Retail clinics can treat minor cold or flu symptoms, fevers, rashes, and minor bumps or scrapes. Some retail clinics also have the ability to provide x-rays, treat strains or sprains, or address nausea symptoms.

Urgent care centers, although usually more costly than retail sites, are able to treat a wider scope of issues. Generally speaking, urgent care centers are equipped to address non-life-threatening health emergencies, including:

• Accidents and falls
• Bleeding/cuts—not bleeding a lot but requiring stitches
• Breathing difficulties (i.e. mild to moderate asthma)
• Diagnostic services, including X-rays and laboratory tests
• Eye irritation and redness
• Fever or flu
• Minor broken bones and fractures (i.e. fingers, toes)
• Moderate back problems
• Severe sore throat or cough
• Skin rashes and infections
• Sprains and strains
• Urinary tract infections
• Vomiting, diarrhea or dehydration

These care settings certainly have the potential to cut ED overutilization, although evidence of their effectiveness is mixed.

While early statistics showed that retail and urgent care clinics actually increased healthcare costs – patients accessed these convenient settings when they otherwise would have allowed symptoms to play out – more recent data shows that they are now making a dent in ED overutilization.

A research note authored by economists from the Federal Reserve Bank of Chicago, Princeton University, and Northwestern University recently showed that retail clinics can cut emergency department utilization, especially when patients live close to those clinics.

The researchers conducted an analysis of the types of ED visits for New Jersey residents who lived between zero and two miles from a retail clinic and those who lived two to five miles away from a retail clinic, hypothesizing that those who lived closer to a clinic would see fewer ED visits.

On the whole, the researchers were right. During a retail clinic’s closed hours, ED utilization for both groups was about the same, indicating that most patients will visit the ED if they have nowhere else to go.

But when the retail clinic was open, patients who lived close by were far more likely to access low-acuity care there than in the ED.

ED visits for primary care preventable diseases also fell when a patient lived closer to a retail clinic. Treatment access for urinary tract infections, upper respiratory infections, ear infections, sprains, and strains all fell by about 6 percent when an individual lived close to a retail clinic.

Driving patient education about access

Of course, offering access to lower-acuity settings is only effective if patients know about those settings and know that their ailments can be treated there.

But a 2017 survey conducted by CityMD revealed that most patients are unable to determine whether they should access services in an urgent care or retail clinic or visit the ED. When prompted with certain medical scenarios, patients were not always able to select the most appropriate care setting for the hypothetical situation.

For example, only 46 percent of respondents correctly selected urgent care as the appropriate choice for a scenario in which a child is presenting with 104-degree fever, shivering, and coughing.

Respondents were also split on scenarios in which a child has a deep chin laceration or an adult has a seemingly endless nosebleed. For both situations, about half of respondents correctly selected urgent care.

The good news is, a majority of patients did know they should visit urgent care or retail clinics when presenting with low-acuity, non-emergent issues. About three-quarters of patients knew to visit urgent care for a potentially sprained ankle or sexually transmitted disease or infection.

And overwhelmingly, patients could identify life-threatening situations that indeed called for an ED visit. Ninety-one percent knew to select the ED when losing consciousness after a bicycle crash and 87 percent knew to visit the ED when presenting with heart attack or stroke symptoms.

Patient education and knowledge about appropriate care sites is likely getting better, the study from the Federal Reserve Bank of Chicago, Princeton University, and Northwestern University found. Even when patients lived close to urgent care or retail clinics, they still utilized the ED for high-acuity cases.

Separate data showed that better patient education about chronic disease self-management can also reduce ED admissions. A 2017 study published in the American Journal of Managed Care showed that an asthma education program boosted self-management and cut ED admissions at Ellis Hospital in Schenectady, New York, lower costs by $230,000.

Driving preventive, primary care utilization

The best way to reduce ED overutilization is to keep patients from becoming sick enough to access the ED in the first place. Preventive and primary care, as well as efforts to address the social determinants of health (SDOH), are essential to keeping patients out of any high-acuity setting.

For Stadter, the MHCP director who manages care coordination around the Milwaukee area, this approach has been intuitive.

“When a patient establishes primary care and has ongoing management of their chronic conditions, there is a better outcome,” Stadter explained. “Patients don't get to the point where it is an emergency and need to go to the emergency room as often.”

This makes the case for strong patient outreach and efforts to get patients into the provider. Many primary care clinics currently lean on automated text messages, phone calls, or emails to remind patients to book their wellness exams and other preventive screenings.

But for more vulnerable populations, getting patients into primary care is harder work, Stadter said. These patients may not know where to access a primary care provider, face transportation barriers, struggle with cultural barriers or face a number of other factors keeping them from accessing care.

These social risk factors have spurred on key strategies. Foremost, healthcare professionals can work with community partners to deploy programs that directly address the SDOH. Rideshare or subsidized transportation programs, for example, have been essential to getting patients to the care they need.

MHCP targets patient navigation and literacy issues, like driving patient education about primary care, connecting them with a provider, and doing all of this in a culturally competent way.

The Partnership, comprised of four Milwaukee health systems, five federally qualified health centers (FQHCs), and other local, community, and state health agencies, identifies patients who visit the ED for a preventable issue and connects them with a primary care provider.

It all begins with an avoidable ED visit, Stadter explained. ED providers mitigate the issue that prompted the visit and then work with caseworkers and other Partnership members to refer chronically ill patients to a primary care provider in their area. Since the program’s 2007 inception, it has connected over 50,000 chronically ill patients with primary care providers and cut ED visits by 44 percent.

In addition to workflow and health information exchange considerations, the program has relied on teamwork between multiple key players.

“At the end of the day, there's a shared mission behind it and a common goal that we want to reduce unnecessary utilization in our community,” he said. “We want to decrease wait times to be seen in the ED, clear out that space, and reduce costs.”

Ultimately, these efforts are effective because they target the biggest issues with ED overutilization. By identifying patients who need access to low-acuity care, making that access convenient, and ensuring the patient understands and feels comfortable with those low-acuity settings, healthcare professionals can effectively address high ED overutilization rates.