Use of a community care coordination team to reduce emergency department utilization and hospital readmissions for the highest utilizers

Methods

Results

A total of 368 patients were chosen to participate in the CCC program during the specified time period. The mean age of the patients was 47.8 (interquartile range [IQR] 37–57); 191 (51.9 %) patients were female, and 177 (48.1 %) patients were male. A total of 182 (49.4 %) patients had no insurance coverage, 115 (31.2 %) had Medicaid, 59 (16.0 %) were enrolled in Medicare, and 12 (3.2 %) reported having both Medicaid and Medicare. Our facility has a high Hispanic population, with English not being the first language of many of our patients. In addition, many of our patients are financially insecure, with 80.7 % (297/368) reporting having neither insurance nor Medicaid. Over the 3.5-year study period, the program participants had an average of 6.3 ED visits prior to enrollment and 2.7 visits post-enrollment (Figure 1), a mean difference of −3.6 visits (42.8 %) (95 % confidence interval [CI] −4.9 to −2.4, p<0.0001). Program participants had an average of 1.6 inpatient admissions pre-enrollment, which was reduced to 0.6 inpatient admissions post-enrollment (Figure 1), a mean difference of −1.1 admissions (37.5 %) (95 % CI −1.4 to −0.7, p<0.0001). The total ED visits of the program participants prior to enrollment were 1,510, which was reduced by 41.6% to 882 post-enrollment (Figure 2). The total inpatient admissions prior to enrollment was 986, which was also reduced by 41.9% to 573 post-enrollment (Figure 2). The participants had no difference in outpatient visits with primary care providers, 0.9 pre-enrollment and 1.0 post-enrollment, a mean difference 0.1 (10.0 %) (95 % CI −0.5 to 0.7, p=0.74).

Figure 1:

A retrospective analysis of the mean ED visits and inpatient hospital admissions of 368 patients before and after CCC team program enrollment over the 3.5-year study period.

Figure 2:

A retrospective analysis of the total ED visits and inpatient hospital admissions of 368 patients before and after CCC team program enrollment over the 3.5-year study period.

Table 2 shows an example of patient interventions. A cost-benefit estimation showed that prior to program enrollment, it cost our institution $5,418,628.30 to manage super-utilizers. The total cost of the program over 3.5 years was $1,294,500.00, and the post-enrollment cost to manage super-utilizers was reduced to $1,615,228.90, yielding an overall cost avoidance of $2,508,899.40 (46.3 % reduction).

Discussion

Frequent use of the ED drives increased healthcare cost in the United States and has been targeted by healthcare-reform efforts [30]. Additionally, hospital readmissions lead to increased expenditure and decreased reimbursements, as well as decreased quality of care and added financial burden to patients and families [21], 22].

Super-utilizers are a small group of patients with complex healthcare needs who consume a very high percentage of healthcare costs and account for frequent ED visits and hospital readmissions. This study shows that implementing a CCC team reduced ED utilization and hospital admissions among a group of super-utilizers. Programs such as our CCC team can bridge financial barriers and gaps and assist with social barriers to healthcare through frequent face-to-face contact, coordinating individual care plans, establishing follow-up appointments, and educating home-management for complex chronic health conditions. Osteopathic medicine has always prioritized caring for underserved populations and partnering with patients to achieve optimal health, which our program successfully accomplishes. The program’s multifaceted approach also looks beyond symptoms to lifestyle factors that may impact patients’ health and focuses on health maintenance and wellness, all of which are long-standing osteopathic principles.

Previous studies have shown that super-utilizers have markedly poor clinical outcomes and higher rates of mortality despite incurring a disproportionate share of the costs [16]. A systemic review of interventions to reduce frequent visits to the ED found that a multi-interdisciplinary approach utilizing case management and individualized care plans decreased mean ED visits, with only one-third of the studies reporting reduced hospital costs [30]. Most of the studies examining similar programs utilized case management and primary care referrals, but our program is unique in that we employ a nurse practitioner as well as registered nurses, social workers, and bilingual community health workers to follow up with patients for an average of 6 months. This comprehensive approach with a built-in primary care provider makes our program exceptionally successful with this vulnerable patient population.

Our study showed positive patient-centered outcomes by reducing ED visits and hospital admissions. We additionally found that implementation of the CCC team saved our institution over $2.5 million dollars during a 3.5-year period. This is an essential finding because hospital administrations would be unlikely to implement such a program if it were not cost-effective. With these findings, we do acknowledge that hospital charges, billing, and revenue figures may vary by institution depending on payer and patient differences.

It is important to note that the timeframe of the data collection did take place during the COVID-19 pandemic, which may have had an effect on our results. Some of our main data points were ED visits and hospital admissions, which were greatly affected by the COVID-19 pandemic.

The ED is an expensive environment for managing chronic diseases and general healthcare needs. Patients who consistently utilize the ED as a source of primary care place unwanted stress and impose unnecessary costs on an already-crowded and financially overwhelmed healthcare system [15], [16], [17], [18], [19], [20].

The Institute for Healthcare Improvement proposed the Triple Aim approach to optimizing health system performance in 2008 [31]. The goal of the Triple Aim is to simultaneously improve the health of the population, enhance individual patient experience and outcomes, and reduce per capita costs for healthcare for the benefit of communities [31]. In subsequent years, the Triple Aim has evolved to also include a focus on the well-being of the healthcare workforce and advancing health equity among the most marginalized patient populations (Quintuple Aim) [32]. Caring for frequent ED super-utilizers who would be better served with a primary care provider is a significant contributor to physician burnout and professional dissatisfaction among ED providers [33]. This study shows that implementation of a CCC team at our facility aligns with all of the arms of the Quintuple Aim and successfully optimized healthcare management for a group of super-utilizers.

Conclusions

Our findings suggest that community programs such as our CCC program can significantly reduce healthcare utilization and the associated cost of care while at the same time successfully improving outpatient management of chronic medical conditions for ED super-utilizers. This program aligns well with the osteopathic principle of the whole-person approach by coordinating individual care plans and giving one-on-one education on home management. The osteopathic principles of emphasis on prevention and wellness and prioritizing dignity in healthcare are also highlighted by the program addressing patients’ underlying social barriers and providing patients with the necessary resources to prevent disease progression necessitating acute care services.