Coordination Program Reduced Acute Care Use and Increased Primary Care Visits Among Frequent Emergency Care Users

Capp R, Misky GJ, Lindrooth RC, Honigman B, Logan H, Hardy R, Nguyen DQ, Wiler JL
Source: Health Affairs
Publication Year: 2017
Patient Need Addressed: Behavioral health, Care Coordination/Management
Population Focus: Complex care, Medicaid beneficiaries
Intervention Type: Service redesign, Staff design and care management
Study Design: Pre-post with Comparison Group
Type of Literature: White
link: https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017.0612
Abstract

Many high utilizers of the emergency department (ED) have public insurance, especially through Medicaid. We evaluated how participation in Bridges to Care (B2C)-an ED-initiated, multidisciplinary, community-based program-affected subsequent ED use, hospital admissions, and primary care use among publicly insured or Medicaid-eligible high ED utilizers. During the six months after the B2C intervention was completed, participants had significantly fewer ED visits (a reduction of 27.9 %) and significantly more primary care visits (an increase of 114.0 %), compared to patients in the control group. In a subanalysis of patients with mental health comorbidities, we found that recipients of B2C services had significantly fewer ED visits (a reduction of 29.7 %) and hospitalizations (30.0 %), and significantly more primary care visits (an increase of 123.2 %), again compared to patients in the control group. The B2C program reduced acute care use and increased the number of primary care visits among high ED utilizers, including those with mental health comorbidities.

Insights Results

Overview of model/article

  • Building off the Camden Coalition of Healthcare Provider’s approach to addressing ED utilization among low-income individuals, researchers implemented Bridges 2 Care (funded by CMS), which consists of multidisciplinary, community-based primary care and care coordination, as well as hotspotting (i.e., using data to quickly identify patterns of high utilization) to reduce ED utilization among low-income individuals
  • B2C was developed collaboratively with the community, healthcare providers, and CMMI. It provides intensive medical, behavioral health, and social coordination services, with up to 8 home visits within 60 days of an ED visit or hospital discharge
  • The B2C home visit team is comprised of a PCP, care coordinator, health coach, behavioral health evaluator, and CHW (all of which were employed by the local FQHC)
  • The cost of building the infrastructure for the program was $500,000 and the ongoing cost is $640/patient/intervention
  • The B2C intervention begins with enrollment, a brief assessment, and scheduling of home visits while the patient is still in the hospital. The first visit occurs 24 – 72 hours after enrollment. At this visit, the CHW and care coordinator complete the enrollment forms, provide contact information, and establish goals. The second visit is conducted by the PCP within 1 week of the ED visit or hospital discharge. At the third and fourth visits (within 30 days of enrollment), behavioral health evaluators and PCPs conduct a behavioral health screening and address acute medical issues. The final 2 visits are conducted by the PCP, health coach, and care coordinator. During the last visits, providers teach empowerment skills and help patients transition out of the program
  • As part of the initial visit, enrollees can choose to be interviewed by a liaison from a community advocacy organization about their experiences, and each 60-day plan can include assistance with obtaining housing, insurance or disability benefits, refugee services, and access to transportation

    Methods of article

    • Cases were defined as people 18+ who had 2+ ED visits or hospital admissions in the previous 180 days and who reported having a PCP at the local FQHC or no PCP. Researchers excluded patients who were pregnant, had substance use disorder (SUD), had recently undergone surgery, had active malignancy, End Stage Renal Disease (ESRD), or those with severe mental illness. Though it targeted Medicaid beneficiaries, it enrolled high utilizers who were not insured but eligible for Medicaid or were insured by Medicare; controls all met the eligibility criteria for cases but were not enrolled because the ED visit occurred when a study coordinator was not present, the patient declined to participate, or the patient was erroneously excluded

    Results

    • Approximately 28% of those enrolled did not complete the 60-day program; 8% were homeless and received their “home” visits at shelters, fast food restaurants, in libraries in parks
    • The groups had no significant adjusted difference in utilization during the 180 days before the index visit. However, during the 180 days after the intervention, the B2C group had significantly fewer ED visits (mean difference: −0.821) and hospitalizations (−0.270) and significantly more primary care visits (1.307) than the control group. In the subgroup of patients with a comorbid mental health diagnosis, recipients of B2C services had significantly fewer ED visits (a difference of 29.7 %) and hospitalizations (30.0 %), and significantly more primary care visits (123.2 %), than did members of the control group
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