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September 5, 2017

Opportunities for Care Coordination in the Emergency Department

The Emergency Department (ED) is a chaotic place, and is unfortunately the start of many patients’ healthcare journeys. The ED has traditionally been an area of healthcare that could benefit from stronger care coordination.

We’ve spent time over the past few months learning from stakeholders and shadowing a number of hospitals in the Boston area. Through conversations with ED Case Managers, ED Residents, Social Workers, Triage Nurses, and even Chairs of Emergency Medicine at different hospitals in the Boston area, we’ve learned a few unintuitive lessons along the way:

First Impressions >> Patient Satisfaction

The Chair of Emergency Medicine from a large Boston hospital cited a study where the patient’s first impressions of a provider institution are crucial factors that drive patient satisfaction. He recalled anecdotes from his own experiences working with patients where a fantastic inpatient experience could still be outweighed by a frustrating encounter in the ED. It was interesting to us how quickly impressions are formed. There are opportunities to support a more streamlined intake of patient history especially if there are encounters that the patient has outside of that particular hospital setting.

PCPs and the ED

Primary Care Physicians (PCPs) are often the best points of contacts to arrange and coordinate care after an encounter at the ED. One of the surprising lessons we’ve learned in exploring the PCP <> ED interaction, is how strong patient-PCP relationships can help to contextualize instructions and form a care plan from the ED to the patient.

ED clinicians we interviewed mentioned use cases where getting a PCP on the phone to speak with the patient while they’re at the ED can diffuse disorientation for the patient and clarify next steps, saving time for both the ED and the PCP.

Multidisciplinary Consults

Though the physician primarily decides on the patient’s ultimate destination, he/she will take input from a diverse team of stakeholders that have contextual insight on the patient’s condition. One of the most important data points is the occupational/physical therapist’s (OT/PT) assessment of discharge readiness. OT/PT’s expertise usually determines the level of rehabilitation or support that a patient may require post-discharge. Because OTs and PTs are traditionally staffed during normal working hours, patients that arrive after or toward the end of an OT/PT’s shift may stay overnight in the ED until an assessment can be scheduled for the next day.

These overnight stays, though not always unnecessary, can be costly to an ED. It can also be a source of patient frustration, since they might be obliviously at-risk for the out-of-pocket costs that can incur from these overnight ED stays.

Caregiver ≠ Medical Readiness

Some of the most at-risk patients present to the ED without an existing support structure to receive them upon discharge. Case managers and social workers can help diagnose a patient caregiver’s readiness. In some situations, it may actually raise red flags that prevent a discharge from the ED to home even if a patient is medically fit for discharge. Conversely, a case manager can advocate for a lower care setting (e.g. discharging home rather than to a Skilled Nursing Facility) if family members/caregivers can demonstrate a strong capacity to support a patient’s more complicated post-discharge process.

Opportunities in this area of ED coordination may include supporting hand-offs in the documentation of this unstructured and sometimes lost piece of information. Better capturing the support and integrating caregivers and family members as part of the follow-up and discharge documentation can also be helpful tools in bridging this sense of caregiver and medical readiness.

Though there are plenty of opportunities to support coordination healthcare, the ED is an important and time-sensitive aspect of patient care that deserves closer attention. Perhaps the opportunities above offer some potential areas to dive deeper into a more coordinated and connected future!


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Tagged: Care Coordination, emergency department, primary care physicians

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