While previous studies have documented the prevalence and ramifications of food insecurity in the ED,the availability of a provider-driven order to improve this condition has not been previously documented. Although food resources are available through a variety of federal and state programs, healthcare providers may be unaware of how to successfully connect patients with these programs.Additionally, the details of the different programs, and understanding which programs apply to whom, can be unclear to patients and healthcare providers alike. Therefore, we believe that referring those patients in need to partners such as Second Harvest Heartland will likely be of greatest benefit to the patients, as these partners focus on one-on-one application assistance and navigation of programs, rather than simply handing out brochures or blank applications in the ED. It is not surprising that using an EMR referral tool improved access to food services in our patient population; the benefit of EMR communication for connecting patients to numerous types of medical and social services has been well documented in the literature.We did, however, identify certain issues with this referral process that are unique to food referrals and unique to the ED. For example, in contrast to the clinic setting where demographics and contact information is updated prior to patient evaluation, in the ED this information is frequently incomplete early in the patient’s visit. If the EMR order was placed without accurate contact information,hydroponic stands the information provided to Second Harvest Heartland was also incomplete. In the early stages of the ED referral, this led to a disproportionate number of ED referrals lacking the necessary contact information and thus these patients could not be reached.

After identifying this problem, the EMR order was changed, requiring the provider to enter an address, phone number, mobile number, or email address, ensuring proper communication to the food bank for follow-up. Ongoing, focused education was valuable in ensuring this aspect of the order was completed for successful referrals. Another important consideration identified during the implementation of this process was realizing the knowledge gaps regarding food insecurity in our ED. Screening for food insecurity is not standardized at intake, nor is it part of the registration/rooming process. As such, in faculty and resident discussions surrounding use of the order, failure to consider food security as part of the ED assessment of patients was perceived to be a key limiting factor in making the food referral. Second Harvest Heartland began systematically visiting clinics and educating staff directly regarding the EMR order; while this helped increase referral volume in the clinics, the ED was targeted later in the roll out. We believe that this highlights the importance of provider education in the ED, as this patient population is at great risk for food insecurity and their needs may not be identified if they are not screened or if they do not use the clinic system. Even with education, concerted efforts and ongoing education are necessary.Frequent users of the emergency department represent a complex group of patients who overuse ED resources. This group accounts for as many as 28% of all ED visits, with the number of annual visits by this group continuing to rise.Frequent users of the ED are defined as patients making four or Community Hospital of the Monterey Peninsula, Division of Emergency Medicine, Monterey, California more ED visits per year; however, some “ultra”-frequent users may make 20 or more visits per year.While the reasons underlying frequent ED visits are often complex and may represent failure of the healthcare system to provide for patients with complex needs, ED frequent users incur significant charges and time for treatment and testing as a part of their evaluation and treatment.

Additionally, as a part of each ED visit, evaluation, and treatment, patients spend time occupying EDs bed and using hospital services such as phlebotomy and radiology.ED bed time and hospital resources are a valuable commodity, particularly as ED visits continue to rise nationwide, making the reduction of such resources by ED frequent users a desirable goal. Case management, as defined by the Case Management Society of America, is a “collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes.”Given the complex medical and social needs of ED frequent users, case management has been extensively used in this group of patients, with multiple studies showing successful reducing in the use of ED services and cost of care in the ED.A 2017 systematic review identified 31 different studies of interventions to decrease ED visits by frequent users.However, despite the large number of studies published, there has been little research on the effect of ED case management for frequent users on length of stay , either in the ED or in the inpatient setting. To the best of our knowledge, this is the first study to evaluate the effect of case management on ED, inpatient, and total hospital LOS for all types of visits by ED frequent users. The goal of this investigation was to explore the effect of ED case management in frequent users of the ED on LOS, both in the ED and the inpatient setting. To better understand the impact of case management in this population,grow table we also chose to look at the effect of this intervention on ED and hospital charges as well as utilization of hospital services. We hypothesized that ED case management would reduce ED visits, admissions, ED LOS, inpatient LOS, charges, and diagnostic studies.We conducted this study at a 225-bed hospital in a suburban area, with approximately 56,000 ED visits per year.

The surrounding healthcare community consists of a variable mix of county-run primary care clinics and private practice physicians – in both primary care and specialty care. There are few free clinics in the surrounding area. Two other hospitals are within 30 miles of our institution, one of which is a county hospital. The study consisted of a retrospective chart review of ED and inpatients visits by patients in our hospital’s Emergency Department Recurrent Visitor Program , comparing the visits made in the one year prior to enrollment in the program, to the visits made in the one year after enrollment in the program.The EDRVP is run by an ED social worker or registered nurse , with emergency physicians, social workers, ED RNs, chemical dependency providers, behavioral health RNs, case managers, and representatives from local insurance providers. At monthly meetings, members of the EDRVP discuss approximately 10 patients who have been referred to the program. If a care plan does not appear to be working to address frequent ED visits or a new issue has come up for the patient causing recurrence of heavy ED use, the patient’s case and care plan is re-visited at the next meeting. If a truly urgent or emergent issue arises, the staff will correspond via secure email or in person to address it and develop new care plans or revisions to existing care plans. The program was developed initially in 2006 by ED staff at our hospital to address increasing visits by frequent users. As the program has grown, additional hospital staff and services have been recruited to assist us with the growing number of patients requiring case management, and to meet newly identified needs of patients in the program. For inclusion criteria, patients are referred to the program for any of the following reasons: concerning ED use ; 10 or more ED visits in 12 months; six or more ED visits in six months; four or more ED visits in one month; or activity by a patient that demonstrates a propensity for future problematic ED encounters – such as violence in the ED or prescription forgery. Patients exhibiting such high-risk activity were believed to be potentially problematic patients, and therefore a plan was developed to preempt frequent, potentially dangerous, recurrent, and problematic visits. There are no exclusion criteria, and patients of any age may be referred. Once a patient has been referred for enrollment in the program, his or her visits are reviewed to determine the underlying medical, psychiatric, and social issues causing the multiple ED visits. A plan of care for the patient is then developed, with the intent to address these issues in the outpatient setting. Care plans may include referring the patient for a case manager, referring the patient to a needed specialist, assisting the patient with unstable housing, or requiring that patients only receive medications from their primary doctor – rather than coming to the ED for refills.

We studied all patients enrolled in the EDRVP between October 2013 and June 2015. For each patient, we reviewed all ED and inpatient visits for the one-year time period before they were enrolled as well as the one- year time period after they were enrolled. Visits were reviewed using the hospital’s electronic medical records system, Sunrise Clinical Manager. We recorded the number of each of the following parameters for the year before and year after enrollment: number of ED visits; number of inpatient admissions; ED LOS; inpatient LOS; ED charges; inpatient charges; number of computed tomography scans; number of ultrasounds; number of radiographs, and number of ED visits at which blood work was performed. Additionally, we noted six main reasons why patients were referred to the program: needing pain management; complex psychosocial issues; complex medical conditions; psychiatric illness; substance abuse; and needing resources or referrals.Six chart reviewers reviewed all of the visits and recorded the data using a standardized data collection spreadsheet in Microsoft Excel. The lead author supervised the chart reviewers to ensure that data collection was standardized and accurate between them. After data collection was complete, we proceeded with data analysis. As we wanted to determine the effect of ED case management on the study parameters listed above, we compared each of the parameters for each patient from the one-year time period before enrollment in the program to the one-year time period after enrollment in the program. To evaluate for statistical significance, we then used a paired Wilcoxon signed-rank test, comparing the year before enrollment to the year after enrollment.Our study clearly demonstrates that ED case management reduces utilization of services, LOS, and cost in a population of ED frequent users. Clearly in the current U.S. healthcare environment, which is characterized by expensive care and crowded hospitals and EDs, this is critical information and may provide some ideas to develop solutions to the problems of high cost and crowding. In reviewing the data on the reason for referrals to the program, it is apparent that this group of patients has complex needs, with less than a third of the group being referred to the program to address only one issue. This supports the need for a comprehensive case management program like the one we have instituted, as we believe that addressing only a single issue underlying recurrent ED use may not decrease ED utilization. From an ED administration standpoint, the most compelling piece of data appears to be the effect of ED case management on LOS. EDs across the U.S. struggle with crowding, often with critically ill or injured patients being forced to wait in waiting rooms when no beds are available. Our study showed that ED case management for ED frequent users helps this problem in two ways. First, by reducing ED visits and ED LOS, the program directly decreases the amount of ED bed time occupied by these repeat visitors, freeing up beds for patients in the waiting room. Second, by reducing inpatient LOS, ED patients are more likely to have inpatient beds available when needed, reducing the frequency of ED boarding. With less ED boarding, there is more available bed time in the ED for new patients from the waiting room. This increased ability to place new patients from the waiting room allows for new patients to be roomed much more quickly, allowing for critically ill and injured patients to receive time-sensitive treatment more quickly and reducing the door-to doctor time for all patients in the department.