In recent years, the emergency department (ED) has become the primary source of care to an increasing number of patients. Data from the 2006-2009 National Hospital Ambulatory Medical Care Survey found that 10.1% of ED visits were identified as nonemergent.1 These nonemergent cases divert limited resources from true emergency situations and represent poor cost-effectiveness for treating such cases.2 In 2008, the average charge for a nonemergency ED encounter was $2101, whereas the average charge to an outpatient provider was $203.3 This implies the opportunity for more than $1800 in savings for every nonemergency ED encounter that is replaced by an office-based encounter. There is strong economic justification to divert patients into primary care with a cost-effective, culturally tailored, outcome-focused approach that endeavors to support patients in preventing and managing health conditions.4
The Greater New Orleans region provides an example of where efforts to prevent nonemergent ED use are needed. A 2010 Kaiser Family Foundation Survey found that 51% of uninsured adults in New Orleans reported the ED as their usual source of care. In 2012, the Greater New Orleans region had approximately 126 000 uninsured adults younger than 65 years, with approximately 80 000 of these adults living under 200% of the federal poverty level (FPL).5 Connecting people to a source of continuous and high-quality primary care, improving perceptions and accessibility to primary care clinics, and reducing barriers to primary care treatment can help avoid the need to use the ED as the first line of engagement.6 One such way to do this is through patient navigation (PN).
Patient navigation is a patient-centric service delivery model that facilitates movement through the complex health care continuum (prevention, detection, diagnosis, and treatment). Facilitators (ie, navigation coordinator or champion) are used to help the patient address barriers throughout the health care system.7 The efficacy of PN programs has been well researched, particularly in relation to cancer care, where it was first introduced to eliminate barriers to screening, diagnosis, and treatment.6,8 Recently, PN has expanded across the health care continuum and has been shown to be potentially helpful in connecting patients to appropriate services, reducing gaps in care, and increasing patient.7,9 There is evidence that suggests that PN integrated into the ED and other case management techniques can help reduce the number of primary care–related ED visits and that these navigation programs are more cost-effective than the ED visits themselves.6,10,11
With expanding PN into general health care and increasing the numbers of individuals eligible for PN services, efforts are needed to improve efficiency while maintaining the quality of PN efficacy. Most efforts to combat inappropriate ED usage focus on PN or nonclinical support helping reduce barriers to care6; however, methods of using data and technology to improve coordination have received limited attention. Little research has been done on the combination of clinical data, risk stratification, and nonclinical support services in both the ED and primary care settings. This combination initiative has been described as crucial to defining regionally relevant solutions to better manage patients, particularly those with chronic conditions and behavioral health comorbidities.12 The primary purpose of this article is to describe the Greater New Orleans Community Health Connection Primary Care Capacity Project Quality Improvement Initiative (GNOPQii), a pilot project aimed at improving the efficiency of PN through an applied data and technology program. Clinic comparisons pre- and post-GNOPQii program are also described. The secondary purpose is to demonstrate the efficacy of GNOPQii embedded within a PN program at reducing nonemergency ED utilization among a high-risk population.
GNOPQii pilot program
The GNOPQii pilot program was funded under the Primary Care Capacity Project (PCCP) of the Gulf Region Health Outreach Program (GRHOP) and administered by the Louisiana Public Health Institute (LPHI). PCCP was one of 4 programming components under GRHOP and aims to expand access to integrated, high-quality, sustainable, community-based primary care and to establish linkages for patients to behavioral health services. GNOPQii was developed to enhance evidence-based care management for Greater New Orleans Community Health Connection (GNOCHC)–enrolled patients who have had, and therefore are at a high predictive risk of having, avoidable ED encounters or inpatient readmissions. GNOCHC is a Medicaid waiver issued to uninsured residents in Louisiana Health District 1 encompassing Orleans, Jefferson, St Bernard, and Plaquemines Parishes. The partnering Federally Qualified Health Centers (FQHCs) were equipped with actionable ED utilization data (real-time notification of a patient check-in for ED visit or hospital admit/discharge summaries) from the Greater New Orleans Health Information Exchange (GNOHIE) to integrate with their own patient clinical data. Each FQHC appointed a point person for communication and receipt of the data packages. The GNOHIE Provider Portal enabled providers and care managers to view patients' longitudinal medical records across multiple ambulatory clinics and hospitals through a secure, patient-centered online interface. Each community clinic operator also received a monthly analytic package that could be queried to identify frequent ED users, trends for day most popular for ED visits accrued across the patient panel, number of ED visits, date of last clinic visit, and depression screening results.
In addition to the utilization of clinic data, GNOPQii was designed to provide resources to identify and address cultural and behavioral barriers to seeking preventive and primary care. The pilot design included the use of patient navigators to address the nonclinical cultural and behavioral barriers to care. For this, GNOPQii contracted the Health Guardian Program of Catholic Charities of Greater New Orleans, an evidence-informed physical and behavioral health care navigation support system, as the PN.13 The team of 7 Health Guardians were contracted, trained, and placed in the FQHCs internally by Catholic Charities. The pilot provided services to a maximum of 100 revolving patient slots, up to a maximum of 400 patients over 2 years; throughout the duration of the pilot, 337 patients were referred into the program. Clinical sites were encouraged to refer patients who were a challenge for their teams in maintaining compliance for health maintenance. Patients were required to have 2 ED visits or hospitalizations in the last 6 months and 2 or more chronic conditions to receive a referral into the PN program. Clinic teams referred in a manner of 3 ways for referral into the program: (1) directly by the clinic staff; (2) clinical staff generated a list of patients to refer to the patient navigators, who then contacted patients directly; we referred to this as the “cold call” method; or (3) navigators were stationed at clinic sites and introduced to patients during a clinical visit, a method we named a “warm handoff.” Patients self-selected to enroll into the GNOPQii pilot program, and patient navigators completed a survey tool to engage patients to self-identify barriers; this information was used to develop the care plans for the patients. Care plans included home visits, family involvement, and patient accompaniment to primary care visits. Patients were able to stay enrolled into the program for up to 90 days, upon which, it was determined by the assigned patient navigator if the patient was ready for graduation. Carryover patients were reassessed every 30 days, where challenges and barriers were reidentified and new plans were put into place. As patients graduated from the navigation program, the clinic point person was notified and additional referrals were received to fill slot positions.
In addition to data informing clinic care, the GNOPQii analytic packages allow for evaluation of outcomes through the GNOHIE Provider Portal. The evaluation utilized data available through the GNOHIE and through concurrent and recent programs to minimize the need for primary data collection. As part of the overall evaluation, comparisons of data utilization and PN services pre- and post-GNOPQii were conducted. Success of the program was defined as patients graduating from the program. Graduation from the program entailed patients resolving barriers, compliance with their health care plan, and no ED admissions for 90 days. Patient interaction and engagement by the Health Guardians was approved under IRB #9000 from Louisiana State University Health Sciences Center–New Orleans (LSUHSC-NO). De-identified patient data were accessed through a data usage agreement between LPHI, LSUHSC-NO, and the participating clinics.
A total of 337 referrals were made and 145 patients were enrolled into the GNOPQii pilot program. Participants were between 19 and 64 years old (M = 40.2 years), at or below 100% of the FPL, and who otherwise had no medical insurance at time of enrollment. The majority of enrollees were female and black or African American; 93.2% had at least 1 encounter at a hospital or clinic that is connected to the GNOHIE, and of those, more than 90% had at least 1 clinical encounter. According to PN care plan documentation, the direct services needed the most by patients were transportation and medication resources. Results demonstrating pre- and post-GNOPQii descriptions are presented in the Table. Results show that after implementation of the pilot, clinics received ED notifications along with a detailed visit summary and patient ED utilization patterns. Of those who enrolled (N = 145), 63 patients graduated, meaning program compliance and 90 days without visits to the ED, resulting in a 43% success rate.
GNOPQii was a 2-year pilot, aimed at reducing nonemergent utilization and 30-day inpatient hospital readmission among a high-risk population in the Greater New Orleans area to produce better health outcomes and appropriate utilization of primary health care services. This initiative provides a regionally relevant solution to better manage patient care and patient-level data, particularly those with chronic conditions and behavioral health comorbidities.12 As shown in the Table, patient navigators were stationed both in the ED and at various clinic locations and had a greater ability to engage patients by direct or provider referral in both of these locations; furthermore, colocated PN services allow for more clinic staff engagement and timely and informative services, leading to increased patient volume.
The results of the pilot suggest that clinic sites were better equipped to make sound decision on care plans and transitioning patient from a hospital stay to primary care. Many of the clinics were able to use the GNOHIE data in decision making for referrals into the GNOPQii pilot and their population health efforts. Data also gave the clinical teams options on how and when to reach out to patient for follow-up. The online portal and analytic data packages, central to GNOPQii, aided in decision making on the part of providers and care managers about how to target their resources toward individuals most amenable to changing ED use. Further data-informed PN services also helped patient retention and to address any barriers, which may hinder this patient population from successful completion of health plans and a better use of resources for overall improvement in health outcomes.
The marker of success through the program was demonstrated by a 43% retention or graduation of the program, where these patients were compliant with their health care plan, made strides to overcome perceived barriers to care, and were able to stay out of the ED for a nonemergent issue for 90 days. If an estimated $1898 savings for every nonemergency ED encounter replaced by an office-based encounter3 is applied to our results, the GNOPQii program contributed to a minimum of $119 574.00 savings if only 1 deterred ED visit per graduate. This estimate is likely to be low, given the increased cost of health care, reduced ED visits for patients who took longer than 90 days, and benefits of additional services provided. Future research should explore the contribution of these factors and improve understanding of barriers to patients who did not graduate or enroll into the pilot.
Implications for Policy & Practice
- GNOPQii provides methods of using data and technology to improve coordination and reduce ED visits.
- The pilot provides an applied model on combination of clinical data, risk stratification, and nonclinical support services in both the ED and primary care settings.
- GNOPQii delivers a promising model that may have utility in other areas for managing patient care.
- The pilot provides a model to connect patients to high-quality in-network primary care providers, therefore more appropriately utilizing health care services available.
Throughout the course of GNOPQii, many lessons were learned, including what did not work well. One of the greatest challenges to overcome during the pilot was the changing of electronic health records (EHRs) during the pilot period; 3 of the clinic partners underwent a change in EHR vendors. As a result, connection to the GNOHIE interface was interrupted and a direct e-mail account had to be put in place to meet the information exchange needs of those organizations, resulting in a slower response rate for the affected clinics in reaching out to patients with recent ED visits. During the pilot period, there were also times in which the normal GNOHIE connection was down for 2- to 3-week periods, resulting in clinical sites receiving notices of hospital and ED visits late, thus affecting the response of the clinics to the patients. Finally, it was noted, all of the participating clinical organizations did not fully use all of the services available to them throughout the pilot period. Currently, efforts are underway to explore sustainability initiatives for the pilot program now that Louisiana is actively participating in expanded Medicaid, increasing the pool of eligible patients. Future research is also needed to systematically test the efficacy of GNOPQii in reducing nonemergent ED visits.
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