Thousands of people move to San Diego each year, but some don't buy any real estate or even rent there. They live, instead, on the street. And when they get sick or beaten up or otherwise overwhelmed, they often end up at Hillcrest, an emergency department that is an old hand at treating homeless patients. Now, however, it is also an old hand with some impressive new moves up its sleeve.
In what may be the most sustainable cost-saving approach to overuse of emergency care by a tertiary care center anywhere in the United States, the ED staff at Hillcrest — a hospital perched amid bungalows on a bucolic city summit — is demonstrating how to cut loss, boost patient satisfaction, and prevent recidivism in a place with the dubious distinction of having the third highest homeless population in the country, a census that ticked up another nine percent last year in this beachside city.
Hillcrest, a part of the University of California, San Diego Health System, accounts for the majority of patients admitted to UCSD medical centers. Yet most of the homeless who have sought care there don't require hospitalization. In fact, they generally have lower comorbid status than other patients, though a fourth of the frequent psychiatric users do have significant medical comorbidity, and they are among the very patients likely to be seen more often than any other group, becoming “super users.” These patients, who once accounted for one in every 37 patient encounters in the ED, included a cohort that visited the ED more than 20 times annually.
Super users have an impact that can encroach enormously on any ED's resources, according to a study of California EDs by the UCSD team. All but three percent of patients are occasional users, but of these, a tiny fraction constitutes super users who are responsible for nearly four percent of all ED visits.
But not anymore at Hillcrest. This patient population was targeted slowly but surely through a team effort by staff, with the help of community partnerships and in conjunction with the EMS, by pilot studies and as a result of painstaking research. The latter is perhaps not at all surprising given the history of the investigators. Ted Chan, MD, the chair and a professor of emergency medicine at UCSD, Edward Castillo, PhD, MPH, a member of the emergency medicine research faculty, and several other colleagues have been attacking challenges to ED care for years. Many members of the team currently addressing treatment of the homeless in the ED, for example, also were working together more than a decade ago to fix problems of ambulance overuse and diversion. (Ann Emerg Med 2004;44:295.)
In a roundtable discussion on the Hillcrest campus, Drs. Chan and Castillo along with other members of the team discussed the problem-solving approaches they believe may serve as a possible guide for other EDs grappling with the same impoverished “super user” phenomenon. These high-use patients incur an estimated $2,400 in cost on average. (Hosp Health Netw 2012;86:24; http://bit.ly/17G7fUj.)
“We see a lot of these patients, and not just because of homelessness,” Dr. Chan said. Many have substance abuse and mental health issues. Some have been thrown out of work by the recent economy. One patient looked like any mom you might see in the supermarket but was without any support, Dr. Chan noted, adding that the “range of social determinants” means the uninsured, even when homeless, are not easy to spot.
But the system's electronic health record can do just that: issue a notification of a super user. An emergency physician then provides a medical screening exam followed by an order for community placement. The emergency nurse evaluates the patient to determine the appropriate venue for community care, and many are transported to these destinations. For frequent users who are low-income and uninsured, the hospital's health information technology links to local community clinics, generating a referral for the patient and a clinic notification. Patients are given their appointment time at the clinic, a map to it that includes which bus route to take, and a simple explanation about why they are being referred.
Frequent users at Hillcrest are defined as being seen six times in 12 months; super users generally have at least double that number of visits, a hugely disproportionate part of ED care, Dr. Castillo pointed out. “But for some ... maybe they have minor illness, then a small wound, then something else,” perhaps a complication because of infection. It adds the need for visits without a system that helps them access health care elsewhere, he said.
Some still slip through the cracks even with Hillcrest's system, Dr. Chan said, but this scheduling approach means not nearly as many do. “For an urban setting like ours, this has been impactful,” he said. An early study showed that almost 25 percent of these patients used the clinic to which they were directed, compared with only one percent who were given traditional discharge information, which included the phone number of a clinic to call. (Ann Emerg Med 2009;54:279.)
The savings in one of the UCSD pilot studies showed a reduction in ED charges by $220,000, representing a 32 percent drop. The number of high users of ED resources at Hillcrest plummeted by almost a third. (Prehosp Emerg Care 2012;16:541.)
Only a few years ago, frequent users, particularly those who constitute extremely high users, were thought to account for a very small part of ED costs. (Ann Emerg Med 2011;58:53.) But the team at UCSD has shown they can be significant. “Many EDs face this,” said Dr. Castillo. About 20 percent of most ED visits are by frequent users, said Howard Mell, MD, an ACEP spokesperson on this issue and the medical director for the Newark, OH, Division of Fire and EMS.
Psychosocial factors often underlie this overuse in Dr. Mell's experience: The elderly, isolated woman who makes calls to 911 so frequently that paramedics know her by name, the young woman molested by a family member who comes to the ED citing back pain instead. Finding the underlying reason for the visits — loneliness in the former, rape in the latter — meant that these problems could be addressed and managed in a way that greatly benefited the patient and sharply reduced the need for so many ED visits, he said.
Last winter, Hillcrest's ED nursing team identified more than 200 patients as super users. Thus was born the Emergency Department Community Placement Project. Characteristically, this segment of patients isn't just homeless with psychiatric disorders but commonly struggle with substance abuse, too.
Locating facilities for treating these patients, particularly for help with addiction problems, became the priority and focus of Karen Mitchell, RN, MSN, a clinical nurse educator and the outreach manager at Hillcrest. Beds now are routinely available for these patients because they contracted with a local “sobering center” and homeless-prevention program and thanks to funding by UCSD Health Systems. “The goal is to get them to the right service and the right approach,” said Ms. Mitchell, who now is at work on a doctorate, in part because of her research with the Hillcrest team. The program took countless phone calls and numerous site visits, but it means lives are saved right along with costs, she stressed.
Patient satisfaction scores have also increased by about six percentage points since that time, and recidivism has been reduced by more than half and by more than three-fourths during some periods. Such statistics have been achieved in part by bed availability that now is guaranteed through agreements between the Hillcrest ED and local charitable organizations, such as Volunteers of America and the Society of St. Vincent de Paul.
The current Hillcrest program built upon some fundamentals gleaned from ambulance-use data several years ago. A pilot study, the San Diego Resource Access Program (RAP), showed that a case-management approach that connects homeless patients with organizations that provide care for this demographic can substantially curtail ambulance trips. Before the RAP study, paramedics had transported 933 patients five or more times, translating into 11 percent of all such transports. After the study, which involved about 50 of the high-use patients, 10 actually had no ED visits at all, presumably because they received effective treatment elsewhere.
RAP, which originated at the city's EMS, addresses these super users regardless of housing status. The pilot program demonstrated the feasibility for EMS to connect them to appropriate resources, reducing ambulance transports and ED visits. “UCSD ED [now] has their own case-management and referral program that places high-impact patients in some dedicated beds,” explained James Dunford, MD, San Diego's medical director and a professor emeritus of clinical medicine and surgery in the department of emergency medicine.
Another program that has shown striking savings is “Project 25,” which identified the 25 heaviest users among the homeless as defined by EMS and ED use and by law enforcement and mental health agencies. Conceived by Dr. Dunford, along with executives from United Way, Project 25 recipients are given housing and care by case managers dedicated solely to this population, he explained.
UCSD is far from the only ED to have put such effort into frequent users, especially the super users among them. Similar programs are underway across the country; some are nowhere near cities like New York and Los Angeles, the two metropolitan areas that top San Diego in homeless residents. The emergency staff at St. Luke's Hospital in Cedar Rapids, IA, for instance, identified 103 patients who had been to the ED more than 12 times over the previous 12 months. Using a case-management approach similar to UCSD's, the hospital saved nearly a million dollars over a nine-month period, according to a report the facility released in 2013.
Studies from the National Hospital Ambulatory Medical Care Survey of EDs have begun calling for renewed emphasis on discharge planning to “medical respite environments” for homeless patients. (Public Health Rep 2010;125:398.) Some medical education is now aimed at developing doctors who understand how essential community partnering can be in terms of instituting preventive care and in curbing over-reliance on the ED. (J Public Health Manag Pract 2011;17:363.)
“This is a no-brainer for the government and the health care industry,” said Mark DeHaven, PhD, the Dean W. Colvard distinguished professor of public health sciences at the College of Health and Human Services at the University of North Carolina in Charlotte. Good evidence shows that prevention pays off, not just in terms of patient health and hospital cost but in “goodwill and desire to help,” he said. “We tried to organize this ‘non-system’ and wanted to show that by using this prevention-oriented system we could produce a tangible and valuable medical ‘commodity,’ namely, reduced ED utilization, even among vulnerable high-risk patients — and we did it,” he said.
Dr. Mell said he likes the term “vulnerable” to describe these patients. In fact, he prefers it to all of the others, from frequent flyers to super users. Repetitive use of the ED, in many cases, represents only “our most vulnerable patients,” he said. “We've got to remember that, for some, we are the place — sometimes the only place — they seek refuge.”
Everyday Medicine for Physicians
Frequent flyers are a frustrating reality of life in the ED. Listen to Dr. Ryan Stanton's podcast as he discusses tools that can help alleviate the super user phenomenon. Find his audio blog, Everyday Medicine for Physicians, only on EMN's website: http://bit.ly/EverydayMedicineMDs.
It Takes a Community
Read an editorial by Dr. Edward Castillo explaining how UCSD rallied the community to institute its program on p. 3.