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Viewpoint: It Takes a Community

Castillo, Edward M. PhD, MPH

doi: 10.1097/01.EEM.0000441176.34748.9a

Dr. Castillo is an assistant adjunct professor of emergency medicine at the University of California, San Diego.



ED crowding increases as resources diminish, leaving communities to identify novel approaches to improve patient care while decreasing costs. One approach is to identify and address the needs of ED frequent and super users who utilize a disproportionate share of acute care resources. (The New Yorker 2011;24:40;

The extent of this issue can vary by community and affects many providers including first responders and emergency physicians. Identifying these patients can potentially allow hospital systems and other agencies to intervene with more consistent management and reduce inappropriate or preventable acute health care utilization. Identification can be difficult, however, and the extent of the issue may not even be known.

Using data from the California Office of Statewide Health Planning and Development, which includes ED and inpatient visits from non-military hospitals in our region, we identified frequent and super users and their utilization in the county. The vast majority, 70 percent of frequent users and 97 percent of super users, visit EDs at multiple sites. When community-wide data are not utilized, individual hospitals are limited to their own hospital-specific visit data for identification of frequent users, resulting in under-identification of these individuals in the community who often use multiple hospitals. Our data indicate that individual hospitals could only identify 16–62 percent of all frequent users and 0.3–15 percent of all the super users using their own data compared with the community-wide approach. (Ann Emerg Med 2012;60[4]:S102.)

Several approaches have shown promise to help decrease the impact of frequent and super users. We implemented continuum of care and case management programs on a hospital level to help decrease recidivism. (Prehosp Emerg Care 2012;16[4]:541.) Other initiatives in our community are targeting frequent and super users by leveraging health information technology. Our region, using the Beacon Community Program which was funded by the Office of the National Coordinator for Health Information Technology, has implemented several initiatives aimed at increasing community care coordination among these and other patient populations.

The largest investment of the San Diego Beacon Community was a regional health care information exchange, which was implemented and is currently expanding. Health care providers now have access to information from visits at other participating institutions. This will provide a new opportunity to help prospectively identify frequent users across multiple health care facilities in our community. Such identification would be the first step in developing strategies to provide more appropriate care and referral for these patients.

Other regional approaches include community-based care coordination, including San Diego Resource Access Program (eRAP) and Care Coordinator Direct Messaging. eRAP, which is headed by the City of San Diego Emergency Medical Services, is a partnership of community agencies, health care providers, and stakeholders. This program identifies the geographical location of service utilization for known frequent ED users in real time to achieve optimal cost-effective care by linking patients with primary care settings and supportive services. “Hot spots” of frequent EMS use are also readily available and regularly monitored for potential interventions. For Case Coordinator Messaging, we partnered with community-based care management programs to set up direct messaging from hospital electronic medical record admit, discharge, and transfer (ADT) systems to notify case managers and providers when one of their clients is seen at a facility. This has shown to be valuable in maintaining the continuum of care and reduce ED recidivism.

Many challenges and opportunities exist as we move forward with health care reform, one of which is how the needs of populations such as frequent and super users are addressed. To do so, it will be important for continued community-wide collaboration and taking advantage of the technical innovations.

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