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Looking for a way to reduce "frequent flyers" in the emergency department (ED)? The answer could be as simple as weekly meetings to review cases and connect frequent ED visitors to community health resources, Eileen Kardos, LCSW, a high-risk navigator at Norwalk Hospital in Connecticut, said Thursday at the annual Population Health Colloquium hosted by Thomas Jefferson University.

In the time since the meetings were started, Norwalk has had "had a significant reduction in our ED high-utilizer population," Kardos said. "We've discussed well over 500 patients, and we have seen a solid 50% reduction in the number of visits made by the population of patients coming in six or more times in a 6-month period. And there has been a 30% to 40% reduction in the number of patients coming in at that threshold, which we found to be pretty exciting."

At the meetings, members are given brief overviews of cases, and then they create individualized care plans to reduce unnecessary hospital usage and improve patients' health outcomes, she explained.

Defining the Population

Hospitals setting up such meetings need to first clearly define what population they're looking at, Kardos said. For example, "the frequency for our program is six visits in 6 months. This can clearly change based on the needs of your hospital. So if you're a really big hospital with a really big census, you might want to start more in the 7-to-10 range; it really just depends on the kind of the initial population when you're first seeing who's coming in.

"It's also possible to set up your program that follows specific diagnosis for patients coming into the ED under specific clinical profiles. It's really up to you," she added.

No matter how you define frequent utilizers, "you are going to want to have a system that identifies the patients and tracks them in real time," said Kardos. "At Norwalk, we have a system in our electronic medical records that will actually flag the patient once they have hit the threshold. So that means a little triangle pops up next to their name, and you can see that on the ED tracking board."

It's also helpful to get a retrospective report every month on who has met the high-utilizer threshold, to make sure the hospital isn't missing anyone, she noted.

Once the target patient population has been determined, it's easier to decide who should be at the meeting and how often to have it, Kardos continued. "For us at Norwalk, that really means we need our emergency department chairs to come in and attend the meetings; we also have found success having strong representation from the Department of Psychiatry, and we have great success bringing in the other community health programs that we have ... It's important to have someone who has a behavioral health background as part of the team" as well, since most of the interventions focus on changing patients' health behaviors, she said.

And, as the high-risk navigator, Kardos sets the meeting agenda, runs the meeting, and does most of the case presentations.

Tackling Barriers to Care

As to the meeting length, "I'm able to keep the meeting under an hour. We really try to keep it pretty brief," she said. "We don't go into in-depth case reviews; we spend a lot of time talking about what has occurred at the last hospital visit, and what the next action steps are. Generally we're talking about 10 to 20 patients a week, and anywhere from two to five new cases weekly."

Discussions often include the patients' social determinants of health, which can be determined from an unstructured interview with the patient, she noted. For example, for a patient who uses the ED for primary care, the team will find out "if the patient has a primary care physician in the community, who this provider is, and any barriers that might exist ... You might identify that something like transportation is an issue, or childcare is an issue," and then work on removing whatever the barrier is, she said.

When connecting patients with community resources, a "warm handoff" sometimes works well, Kardos noted. "I might connect with the community provider ahead of time, share some of the concerns on the patient's behalf, talk about what many of the visits are like in the hospital, and then I might even go so far as to attend the first appointment with the patient, until I know for sure that the patient has connected to this new provider and that this new provider is going to take on most of the work."

Managing the Workload

The meetings can also help provide in-hospital support. For instance, a patient may have come into the ED for an opioid overdose and be admitted, "and it looks like they are getting started on methadone, but we really need to follow up with that in the community," she said. "I might connect with the attending physician or social worker on the floor and discuss options for community providers that I already have relationships with, that I know would be a good match for this patient."

Conversely, for a patient that comes to the ED for pain management, "we might be able to find out that this patient already has a primary care provider who is managing their pain, or a pain management doctor, so ... we might do some care coordination protocols to get recommendations from the treating community physicians for when the client comes into the emergency room," said Kardos.

"From there we might set up a specialized plan that would pop up and be in the chart. So the next time the patient presents to the emergency room, there is a specific medication protocol that their treating doctor is recommending, and that's going to pop up for the physician who is treating, or the attending physician in the ED," she said.

The team also needs to focus on managing its workload, she advised. "This patient population can become large, and it also can feel overwhelming. You want to stay away from becoming the actual case manager for these patients, and you really want to work as much as you can through other teams and other providers ... If you're doing all the case management work yourself, you will not have time to run the program or to grow it."

One way Norwalk Hospital eases the burden is by using rotating teams of nursing and social work students from a nearby university to do some of the work, such as making calls to community providers, reaching out to patients, and even doing some home visits, Kardos explained.

This effort has both benefits and challenges, she added. On the benefits side, it's very low cost. "I'm grant-funded on a social work salary." In addition, "this is a supportive program to ED staff who can feel really burned out and maybe a little bit tired from some of the challenging high-utilizer populations."

Challenges include the need for leadership buy-in and frustrations with high utilizers with substance use disorders who aren't willing to get treatment. "This can be for extended periods of time, and that can be hard when you have made a lot of interventions and now you are left with a tougher population," she said.

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