Care Coordination, Community Health Workers Reduce ED Costs, Use

January 02, 2018 - Average direct emergency department costs dropped 15 percent for frequent emergency department users after Brigham and Women’s hospital implemented a care coordination program using community health workers, according to a recent study in the American Journal of Managed Care.

Emergency department-based care coordination also resulted in 8 percent less inpatient direct costs at the large urban academic medical center, reported researchers from the Icahn School of Medicine at Mount Sinai, Brigham and Women’s Hospital, and Harvard Medical School.

“ED-based care coordination is a promising approach to reduce ED use and hospitalizations among frequent ED users,” they wrote. “Our program also demonstrated a decrease in costs per patient. Future efforts to promote population health and control costs may benefit from incorporating similar programs into acute care delivery systems.”

Just 5 percent of patients account for almost one-half of the nation’s healthcare spending, the National Academy of Medicine recently reported. Emergency department use contributed to a large portion of this group’s spending.

To target frequent emergency department users, Brigham and Women’s hospitals launched a care coordination program in October 2014.  A sample of patients who topped the list of most frequent visits during both the 30-day and 12-month period preceding the program joined the demonstration.

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Under the demonstration, Brigham and Women’s hospital developed two aims: to develop acute care plans to guide emergency department care and connect frequent emergency department users with a community health worker to improve care coordination and address social determinants of health.

Emergency department physicians and physician assistants at the academic medical center first conducted chart reviews for the 36 patients randomly assigned to the program. The providers identified medical and social issues contributing to frequent emergency department use.

Then, they created an acute care plan for emergency department care with help from a patient’s longitudinal providers, including primary care physicians, medical specialists, and social workers. They uploaded plans to the EHR and electronically flagged the plans so clinicians could see the plan during an emergency department visit.

The academic medical center also assigned a community health worker to patients in the program.

Researchers noted that traditional case management programs usually employ licensed care managers or social workers to help with patient navigation. However, Brigham and Women’s hospital used public health workers who are “trusted members of and/or have an unusually close understanding of the community served.”

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The community health workers connected with frequent emergency department users in the program either by phone or in person to address medical and social needs outside of the hospital. The workers assisted patients with their individualized needs, including coordinating transportation to clinics, providing information on community resources, and connecting patients to primary care providers.

Community health workers also received notifications when their assigned patients registered at an emergency department. They connected these patients with follow-up care and community-based resources.

Brigham and Women’s hospitals also linked the care coordination program’s two elements by conducting weekly meetings between community health workers, physicians, and nurse care coordinators. The providers discussed patient needs, assessed enrolled patients, and assigned responsibilities for future encounters.

In seven months after program implementation, the academic medical center reported that patients enrolled in the intervention had 35 percent fewer emergency department visits and 31 percent fewer hospitalizations compared to frequent emergency department users not in the program.

The reduced utilization resulted in significant cost savings for the small patient group. Costs decreased $2,247 per patient because of reduced emergency department use and fell $802 per patient because of reduced hospitalization rates.

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The annualized cost savings after program implementation were $117,997 for the academic medical center, resulting in a positive return on investment. Program implementation had an annualized cost of just $55,115.

Brigham and Women’s hospital also realized additional revenue from increased capacity.

Researchers stated that hospitals should consider extending care coordination and community health worker programs to the emergency department. Traditionally, hospitals implement these program in the primary care setting or patient-centered medical home.

However, organizations could benefit from emergency department programs because the setting shows unmet social and behavioral needs in the community. Frequent emergency department users are more likely to have complex medical, social, and behavioral health needs. They also have greater chances of suffering from a chronic disease, reporting lower socioeconomic status, and utilizing all healthcare services.

Community health workers are key to addressing the unique medical and social needs identified through frequent emergency department use.

“The CHW [community health worker] was able to identify unmet social needs contributing to acute care utilization that may not be apparent to busy clinicians and are not readily addressed during a single ED or clinic visit,” the study stated.

Additionally, emergency department-based care coordination will be critical to maximizing value-based reimbursement. Alternative payment models require providers to prevent unnecessary utilization costs. Failing to do so could result in financial losses or penalties.

“As payment and care delivery models shift toward value-based payment models prioritizing population health, it is critical to engage acute care providers, in addition to longitudinal providers, in care coordination efforts,” researchers wrote. “Our pilot program can serve as a model for other interdisciplinary collaborations to improve care coordination and reduce costs.”