This observational retrospective study was performed at a 205-bed community hospital in central California with approximately 45,000 visits to the ED each year. This study was granted IRB exemption by the hospital committee on research.
A case management pilot program was developed by the ED staff to adequately meet the needs and improve the overall care of patients recurrently seeking care in the ED for chronic medical problems, including narcotic or benzodiazepine addiction. The program is chaired and operated by an ED nurse, who oversees a committee consisting of ED physicians, a chemical dependency physician, hospitalist physicians, pain management clinicians, behavioral health physicians and nurses, as well as social service providers. Patients were enrolled in the case management program if they were identified as having five or more visits to the ED in the month prior to enrollment. Patients could also be enrolled if nursing staff or physicians requested a case management evaluation for a particular patient based on patient pattern uses. Additionally, patients could be enrolled if one of the ED physicians received a letter from the California prescription monitoring program regarding a patient. The case management team met once a month for 90 minutes to discuss both patients currently being managed and patients newly identified as needing case management.
When a patient was first presented to the case management team, the chair provided a tally of his or her recent ED visits, with a listing for each of the visits of the chief complaint, studies performed, ED treatments provided, and prescriptions given. Also included were a record of the patient’s admissions from the ED and medical problems including regular medications. Based on this information, the case management team determined the chronic problem or problems underlying the frequent use of the ED and then developed a plan to manage these problems in the outpatient setting. Patient care plans consisted of referral to outpatient resources for the management of patients’ chronic problems outside of the ED. Such resources included chemical dependency treatment for addiction, pain management for chronic pain, psychiatric services for untreated anxiety or depression, and primary care for those without a primary care provider. Patients without insurance could also be referred to social services for assistance in getting Medi-cal/Medicaid insurance. Additionally, to prevent repeat use for the same chronic problems, the team created recommendations regarding what treatments could be given in the ED. For example, the team recommended that patients with chronic pain not receive narcotics for their chronic pain; rather, the patient’s primary care physician (PMD) or pain management physician would be contacted. Similarly, recommendations for patients with opiate or benzodiazepine addiction often involved not using opiates or benzodiazepines except in case of new and acute issues, such as trauma. Patients received letters at their listed mailing addresses informing them of their enrollment in the case management program and the specifics of their plan.
For patients already enrolled in the program, the case management team periodically reviewed all of the patient’s visits to the ED, including those since enrollment. In the case of a significant reduction in the frequency of ED use and adherence by the ED staff to the case management plan, the patient’s plan would be continued and reassessed at a later meeting. For patients with minimal decreases in ED use, the case management team reassessed the patient’s problems to develop a new plan to implement.
Once patients were enrolled, documents regarding their case management plan were placed into the patient’s medical record, allowing EPs and other physicians treating the patient to have easy access to the care plan. Furthermore, to improve adherence to the plan, patients in case management were identified upon arrival to the ED and a note was placed on the ED status board in the comments section to alert treating physicians and nursing staff of the patient’s enrollment in the case management program.
In analyzing data for our study, we used the hospital’s medical record system to obtain data regarding the frequency of patients’ visits, chief complaints at each visit, nature of their care plan, basic demographic information about each patient, referrals attended, and the number of CT scans received. We recorded the total number of CT scan images at each visit to compare radiation exposure from CT scans before and after program enrollment.
Our study had two primary outcome measures. The first was the number of visits per patient per month to the ED, and the second was the number of CT scans per patient per month. We recorded the number of patient visits per month and number of CT scans received per month for the six months prior to enrollment in the program and the six months after enrollment. To assess the efficacy of the case management over a longer time period, all enrolled patients were followed through November 2008, when our study data collection ended. Patient visits per month and the number of CT scans per month were recorded for this time period.
Our study also had three secondary outcome measures. We compared admission rates before and after enrollment in the program as a method of discerning if the case management program was preventing people from seeking care when needing admission. We also evaluated the rate of attendance of our major referrals for the program to determine if patients were receiving the care recommended to them. Of the patients who were referred to obtain insurance, obtained a PMD, received care from the pain management service, received a chemical dependency evaluation, or received an evaluation and care from the psychiatry service, we examined the percentage of our patients successfully receiving these services. Finally, for each patient we determined the most common chief complaints that brought them to the ED for care both before and after enrollment as a means of assessing whether or not the patient’s chronic problems were being adequately addressed. In case a patient presented frequently for two separate issues, both of these were recorded as their most common chief complaint.
We analyzed data with Microsoft Excel 2007, using a paired, two-tailed t-test to generate p values in comparing ED visits per patient per month and CT images per patient per month in the six months prior to enrollment to both the six months after enrollment as well as to the time period from enrollment through November 2008.