Strategies to Decrease Non-urgent ED Usage

How can hospitals and healthcare systems decrease the non-urgent use of emergency departments in today’s healthcare climate? A new report by the U.S. Government Accountability Office (GAO) outlines a number of strategies, including case studies of healthcare organizations that have been successful.

The report found that strategies such as expanding hours and service and improving care coordination through a medical home model can effectively reduce the rate of patients seeking care for non-urgent needs in the emergency department.

And reducing ED usage can save money, since emergency care tends to be very expensive; the GAO report noted that the average cost of a non-emergency visit to the ED costs seven times more than a visit to a health center for the same type of care.

Yet the use of emergency departments seems to be on an upward trajectory.

That trend may reflect an overall increased demand for ambulatory care, noted Peter Cunningham, Ph.D., senior fellow at the Center for Studying Health Systems Change (HSC).

Cunningham recently testified before a Senate subcommittee that most visits to hospital EDs don’t fall into the category of true emergencies, but they aren’t all non-urgent visits, either.

People may see the emergency department as their best—or only—option for getting care when they are able to get it, even if they are not actually experiencing emergencies. And that’s true of people both with and without health insurance; contrary to popular belief, the insured are actually responsible for more of the growth in non-urgent visits to the ED than the uninsured.

According to Cunningham, who is also the director of quantitative research at HSC, ED visits have been on an upward swing over the past 15 years, mostly due to visits by people with private insurance or other health care coverage.

“It just offers certain advantages that are kind of in synch with their needs and their lifestyle and what’s convenient for them,” said Cunningham.

For example, some people find it difficult or inconvenient to take time off from work to visit a doctor, so when they do seek out care it’s after hours and the only real option available is the emergency department.

“Inability to access primary care is definitely contributing to what’s going on in the emergency department,” confirmed Caroline Steinberg, vice president for trends and analysis for the American Hospital Association.

The GAO report found that about 8 percent of the 117 million ED visits in 2007 were non-urgent, but it predicted that the numbers could rise as various provisions of the Patient Protection and Affordable Care Act are implemented over the next few years.

That’s why many healthcare systems are seeking strategies to make sure that patients are able to get the right kind of care in the right kind of setting.

Access Community Health Network, which is based in Chicago, operates with the philosophy that improved access to primary care is a key factor to diverting patients away from the ED when they don’t really need to be there.

Access, which was profiled in the GAO report, offers Saturday hours and extended weekday hours in its network of community health care centers. The system’s clinics also offer same-day walk-in appointments for people who need to see a doctor that day.

“We’re in their neighborhoods,” explained Janie Gawrys, RN, MS, vice president of clinical operations for Access. “We’re not miles away.”

Gawrys said that it also helps when patients have a relationship with their providers and the staff in their neighborhood health centers. Patients might be less inclined to just head to the ED if they have a good relationship with their provider and really trust them to help when they need it.

The medical home model can also be a useful strategy to decreasing unnecessary ED utilization. An August 2009 report from the Patient-Centered Primary Care Collaborative looked at the implementation of medical home interventions and found that investments to improve and strengthen primary care options often resulted in a reduction in ED visits.

“Additionally, better management of chronic conditions, such as diabetes, asthma, and congestive heart failure, could also reduce the need for emergency department visits,” the GAO report authors wrote.

Steinberg noted that as the population ages, the rate of chronic disease will likely continue to increase. Better preventive care—including improved access—can help reduce the likelihood that some patients with chronic conditions will present in the ED with an acute episode.

“Everybody’s really looking for ways to better manage the patients with chronic diseases,” she said, adding that coordinated care systems have the potential to improve that situation.

However, even if patients do have access to a coordinated system of care offered by an accountable care organization (ACO) or a medical home-style practice, it might not necessarily reduce the likelihood that they’ll turn to the ED, said Cunningham. Those organizations would probably have to offer around-the-clock care.

“I think there’s still going to be a gap because I don’t think there are many other facilities that provide 24/7 availability,” Cunningham said.
However, if the number of hospital emergency departments continue to decline, effective strategies to provide care that at least reduces the chances that people will wind up in the ED may become increasingly more important.

The Journal of the American Medical Association (JAMA) published a study earlier this month that detailed the closures of EDs over the past 20 years. The number of hospital EDs shrank by 27 percent from 1990 to 2009, even as the rate of ED visits increased.

Steinberg clarified that the main reason EDs close is because the hospitals to which they are attached close. Many hospitals are feeling extremely pressured by the demands of the Medicare and Medicaid payment regulations, and that could lead to more hospital closures, especially in high poverty areas.

At the same time, however, some health care systems are starting to establish stand-alone EDs, which could meet some of the predicted demand for increased emergency services.

“I think it’s definitely a growing trend,” Steinberg said.

For more information, see the GAO report:

Hospital Emergency Departments: Health Center Strategies That May Help Reduce Their Use