They come by ambulance, or they walk through the front doors of HealthAlliance Hospital’s Broadway Campus’ emergency room. Their numbers spike in the winter and fall when the weather is warm. Common complaints include chest pains and shortness of breath. They’re given a medical workup and sent on their way a short time later, once ER staffers are satisfied they are not suffering from an acute health crisis that would get them admitted to the hospital. A few days — or a few hours — later, they return.
Among health care executives and in medical journals this population is known as “high utilizers” or, more recently, “multi-visit patients.” To frontline ER staff they are known colloquially (though not at HealthAlliance’s hospitals, officials insist) as “frequent flyers.” While a few have chronic medical conditions like COPD and diabetes that require frequent admission to the hospital, the majority come to the ER suffering from a complicated mix of homelessness, mental illness and substance abuse.
The hospital, with its mandate to render assistance to anyone who comes through the door, offers a place to get warm, get a meal and maybe a sympathetic ear. “They have no place to go,” said Mary “Chiz” Chisholm, who runs a Washington Avenue boarding house that caters to the city’s down and out. “And the hospital is the one place where they won’t be turned away.”
Cristy Bauer, director of clinical transformation and quality at HealthAlliance, said the typical multi-visit patient is a male between the ages of 40 and 50. Most are low-income, and 80 percent have coverage through Medicaid. Four out of five have a diagnosed behavioral health issue like mental illness or addiction. Bauer estimates that there are about 150 of these patients the hospital’s emergency department deals with. Of those, she said, just 10 percent were frequently admitted for inpatient treatment.
“They are presenting at a health care organization but they don’t necessarily have an acute medical issue. That’s not really the driver,” said Bauer. “The real issue is that they don’t have a warm place to sleep, they don’t have a place to get a meal. We had one patient who came in because his [EBT] card had broken in half and he couldn’t access his food stamp benefits.”
Bauer said the cost of dealing with such patients was relatively low since they did not have acute medical issues and did not require admission to the facility or costly imaging and lab work. But, she said, the costs add up when you consider that some of the multi-visit patients can clock 100 or more ER visits in a year. They also divert time and resources of ER staff who may be dealing with far more critical medical emergencies.
“Our emergency department staff is highly trained and they’re here to handle traumatic medical emergencies like someone’s who’s had a heart attack or been in a car crash,” said Bauer. “If they have to treat people with social determinant needs who don’t have an acute medical issue, that’s not an appropriate use of resources.”
Working toward solutions
To address the issue of multi-visit patients the hospital has instituted a new position an “Emergency Department Care Navigator.” Equipped with a background in psychology, the care navigator is on-site at the ER 40 hours a week to connect with multi-visit patients and assess their non-medical needs. The navigator has access to a directory of services ranging from primary care doctors to social service, housing and mental health organizations.
Multi-visit patients are flagged with exclamation points in the hospital’s electronics records system. When they reappear in the ER and after they receive a routine medical workup, the care navigator, who has access to records of previous visits, will speak with them and attempt to connect them with services.
Bauer said the goal is to have the navigator become familiar with the patient’s needs and perform follow-up work as needed. “They’re not falling through the cracks,” said Bauer. “When they come back three days later it’s not, ‘Oh it’s you again,’ it’s, ‘How did that work out with that organization I put you in touch with? It didn’t work out? OK, let’s try something else.’”
So far, Bauer said, the program appeared to be paying off. ER room visits by multi-visit patients fell 20 percent between the first quarter of 2017 and the first quarter of 2018. The same trend is reflected statewide, as health care systems work towards solutions to redirect multi-visit patients from ER’s to more appropriate settings.
Part of the push, Bauer said, is a nationwide move towards “outcome-based treatment.” Starting in 2020, Medicaid is expected to put new treatment standards in place that will reward providers based on how well their patients are managing chronic conditions, rather than how many procedures and interventions are performed. So, for example, a hospital might be paid more for getting a diabetic patient connected with an education program and a primary care doctor, thus helping the person to stay out of the hospital — than repeatedly admitting them for treatment of the illness’ acute complications.
For the multi-visit patients, success under the new reimbursement scheme means fewer ER visits. But it also means connection with a primary care physician and other health care professionals outside a hospital setting.
HealthAlliance communications director Gerry Harrington said much of the outpatient support needed by the multi-visit patients would be available at the proposed “medical village” at the site of the current Broadway Campus. (Hospital services would be merged at the former Benedictine Hospital on Mary’s Avenue). The planned facility would include primary care physicians’ offices, behavioral health services, transportation and housing.
Meanwhile, Bauer said, hospital staff are counseling patience and persistence when it comes to dealing with a vulnerable population that has come to see the ER as their refuge of first resort for both medical and non-medical needs.
“You don’t take someone coming to the hospital 27 times in one month and expect them not to come to the hospital at all,” she said. “We take someone coming into the hospital 27 times in one month and try to fix a couple little things so maybe they’re only coming in 17 times next month.”
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