Care Plans Decreased High-Risk Patients' ED Visits

SAN DIEGO – Making specialized care plans for 28 high-risk patients easily accessible to physicians by computer decreased hospitalizations and emergency department visits by 65% over 2 months.

In the 2 months before implementation of the care plan system, the 28 patients visited EDs 122 times and had 59 admissions to the hospital. ED visits decreased to 53 and admissions dropped to 9 for these patients in the 2 months after implementation of the system, an overall reduction of about 65%, Dr. Richard J. Hilger and his associates reported at the annual meeting of the Society of Hospital Medicine.

The study was honored by the Society as one of the best three presentations at the meeting.

"Our financial department says that ideally, in a closed system, that would be a cost savings to society of over half a million dollars just for 28 patients over just a 2-month period," said Dr. Hilger, medical director of Care Management at Regions Hospital, St. Paul, Minn., a part of HealthPartners Medical Group.

Presently, there’s no way of knowing if patients circumvented the care plans by going to another hospital that’s not in the HealthPartners Medical Group, but records suggest that "only a handful of patients have left our system," he added.

The investigators next will try to integrate the care plans among health care systems in their geographic area, "so that care plans can be used from system to system," Dr. Hilger said.

The pilot study focused on three groups of patients with frequent ED visits and hospitalizations: narcotic-seeking patients, patients with mental health diagnoses (especially borderline traits), and patients with a long history of not complying with medical therapy.

A committee of hospital leaders created the specialized plans to restrict care in hopes of redirecting these patients to clinics and their primary care physicians, thus reducing medically unnecessary admissions and ED visits. The committee included specialists from hospital medicine, nursing, emergency medicine, primary care, risk management, quality control, care management, and electronic medical records.

When any physician in the medical group went to the computerized record of one of these patients, an orange bar across the bottom of the screen alerted the physician that a care plan was in place. Clicking on the bar opened a description of the plan, which could be read to the patient.

The "alpha case" that got the hospital team to start the care plan system was a 35-year-old patient named Ann who abused narcotics and had type 1 diabetes, borderline personality disorder, and severe anxiety disorder. Frequently, she would visit the ED in diabetic distress and would refuse insulin unless she was given narcotics. In the 6 weeks prior to institution of a care plan for her, she came to the ED 14 times and was admitted 6 times. In the 14 weeks after the plan started, she visited the ED twice and was admitted twice.

A Sample Plan

Dr. Hilger read an example of a care plan for narcotic-seeking patients, which said that care guidelines were being instituted in order to provide consistent and quality care that maintains the patient’s safety when seen by providers who may not know the patient well. The guidelines are as follows: The patient would not receive IV narcotics in the ED unless there is a medical condition unrelated to chronic pain. The ED should not be used for routine medical care or management of chronic pain, but the physician with the patient would help set up more frequent clinic visits. The ED or inpatient physicians would not fill orders for oral narcotics at discharge. The patient’s outpatient regimen should be used for chronic pain or exacerbations of chronic pain, and IV Benadryl or IV benzodiazepines should not be used for pain control.

The physician should offer substance-abuse treatment programs when appropriate, the care plan continued. Repeated imaging studies such as CT scans were discouraged unless new pathology was suggested by an exam, vital signs, and/or screening labs, because repeated imaging exposes the patient to radiation. The patient should not attempt to obtain narcotic prescriptions from anyone other than the designated primary care provider. If the patient does not follow the rules described in the care plan, the medical group "would have to consider releasing you from our care, since noncompliance leads us to being unable to care for you safely and appropriately."

Dr. Hilger cited a New Yorker magazine article by Dr. Atul Gawande of Harvard University describing the benefits of coordinating care for the most chronically expensive patients. The use of care plans promotes consistency in care; reinforces goals and expectations; empowers patients to take steps toward positive change; fosters patient trust; increases use of primary care; and decreases hospitalizations, readmissions, and total costs, the article suggests.

"We didn’t invent this" idea of care plans, Dr. Hilger said. Many hospitals are experimenting with elements of specialized care plans, but research so far has been limited mainly to EDs, he added. Specialized care plans are becoming popular for the less than 1% of patients with high rates of medically unnecessary emergency visits and admissions.

Dr. Hilger reported having no financial disclosures.

SAN DIEGO – Making specialized care plans for 28 high-risk patients easily accessible to physicians by computer decreased hospitalizations and emergency department visits by 65% over 2 months.

In the 2 months before implementation of the care plan system, the 28 patients visited EDs 122 times and had 59 admissions to the hospital. ED visits decreased to 53 and admissions dropped to 9 for these patients in the 2 months after implementation of the system, an overall reduction of about 65%, Dr. Richard J. Hilger and his associates reported at the annual meeting of the Society of Hospital Medicine.

The study was honored by the Society as one of the best three presentations at the meeting.

"Our financial department says that ideally, in a closed system, that would be a cost savings to society of over half a million dollars just for 28 patients over just a 2-month period," said Dr. Hilger, medical director of Care Management at Regions Hospital, St. Paul, Minn., a part of HealthPartners Medical Group.

Presently, there’s no way of knowing if patients circumvented the care plans by going to another hospital that’s not in the HealthPartners Medical Group, but records suggest that "only a handful of patients have left our system," he added.

The investigators next will try to integrate the care plans among health care systems in their geographic area, "so that care plans can be used from system to system," Dr. Hilger said.

The pilot study focused on three groups of patients with frequent ED visits and hospitalizations: narcotic-seeking patients, patients with mental health diagnoses (especially borderline traits), and patients with a long history of not complying with medical therapy.

A committee of hospital leaders created the specialized plans to restrict care in hopes of redirecting these patients to clinics and their primary care physicians, thus reducing medically unnecessary admissions and ED visits. The committee included specialists from hospital medicine, nursing, emergency medicine, primary care, risk management, quality control, care management, and electronic medical records.

When any physician in the medical group went to the computerized record of one of these patients, an orange bar across the bottom of the screen alerted the physician that a care plan was in place. Clicking on the bar opened a description of the plan, which could be read to the patient.

The "alpha case" that got the hospital team to start the care plan system was a 35-year-old patient named Ann who abused narcotics and had type 1 diabetes, borderline personality disorder, and severe anxiety disorder. Frequently, she would visit the ED in diabetic distress and would refuse insulin unless she was given narcotics. In the 6 weeks prior to institution of a care plan for her, she came to the ED 14 times and was admitted 6 times. In the 14 weeks after the plan started, she visited the ED twice and was admitted twice.

A Sample Plan

Dr. Hilger read an example of a care plan for narcotic-seeking patients, which said that care guidelines were being instituted in order to provide consistent and quality care that maintains the patient’s safety when seen by providers who may not know the patient well. The guidelines are as follows: The patient would not receive IV narcotics in the ED unless there is a medical condition unrelated to chronic pain. The ED should not be used for routine medical care or management of chronic pain, but the physician with the patient would help set up more frequent clinic visits. The ED or inpatient physicians would not fill orders for oral narcotics at discharge. The patient’s outpatient regimen should be used for chronic pain or exacerbations of chronic pain, and IV Benadryl or IV benzodiazepines should not be used for pain control.

The physician should offer substance-abuse treatment programs when appropriate, the care plan continued. Repeated imaging studies such as CT scans were discouraged unless new pathology was suggested by an exam, vital signs, and/or screening labs, because repeated imaging exposes the patient to radiation. The patient should not attempt to obtain narcotic prescriptions from anyone other than the designated primary care provider. If the patient does not follow the rules described in the care plan, the medical group "would have to consider releasing you from our care, since noncompliance leads us to being unable to care for you safely and appropriately."

Dr. Hilger cited a New Yorker magazine article by Dr. Atul Gawande of Harvard University describing the benefits of coordinating care for the most chronically expensive patients. The use of care plans promotes consistency in care; reinforces goals and expectations; empowers patients to take steps toward positive change; fosters patient trust; increases use of primary care; and decreases hospitalizations, readmissions, and total costs, the article suggests.

"We didn’t invent this" idea of care plans, Dr. Hilger said. Many hospitals are experimenting with elements of specialized care plans, but research so far has been limited mainly to EDs, he added. Specialized care plans are becoming popular for the less than 1% of patients with high rates of medically unnecessary emergency visits and admissions.

Dr. Hilger reported having no financial disclosures.

SAN DIEGO – Making specialized care plans for 28 high-risk patients easily accessible to physicians by computer decreased hospitalizations and emergency department visits by 65% over 2 months.

In the 2 months before implementation of the care plan system, the 28 patients visited EDs 122 times and had 59 admissions to the hospital. ED visits decreased to 53 and admissions dropped to 9 for these patients in the 2 months after implementation of the system, an overall reduction of about 65%, Dr. Richard J. Hilger and his associates reported at the annual meeting of the Society of Hospital Medicine.

The study was honored by the Society as one of the best three presentations at the meeting.

"Our financial department says that ideally, in a closed system, that would be a cost savings to society of over half a million dollars just for 28 patients over just a 2-month period," said Dr. Hilger, medical director of Care Management at Regions Hospital, St. Paul, Minn., a part of HealthPartners Medical Group.

Presently, there’s no way of knowing if patients circumvented the care plans by going to another hospital that’s not in the HealthPartners Medical Group, but records suggest that "only a handful of patients have left our system," he added.

The investigators next will try to integrate the care plans among health care systems in their geographic area, "so that care plans can be used from system to system," Dr. Hilger said.

The pilot study focused on three groups of patients with frequent ED visits and hospitalizations: narcotic-seeking patients, patients with mental health diagnoses (especially borderline traits), and patients with a long history of not complying with medical therapy.

A committee of hospital leaders created the specialized plans to restrict care in hopes of redirecting these patients to clinics and their primary care physicians, thus reducing medically unnecessary admissions and ED visits. The committee included specialists from hospital medicine, nursing, emergency medicine, primary care, risk management, quality control, care management, and electronic medical records.

When any physician in the medical group went to the computerized record of one of these patients, an orange bar across the bottom of the screen alerted the physician that a care plan was in place. Clicking on the bar opened a description of the plan, which could be read to the patient.

The "alpha case" that got the hospital team to start the care plan system was a 35-year-old patient named Ann who abused narcotics and had type 1 diabetes, borderline personality disorder, and severe anxiety disorder. Frequently, she would visit the ED in diabetic distress and would refuse insulin unless she was given narcotics. In the 6 weeks prior to institution of a care plan for her, she came to the ED 14 times and was admitted 6 times. In the 14 weeks after the plan started, she visited the ED twice and was admitted twice.

A Sample Plan

Dr. Hilger read an example of a care plan for narcotic-seeking patients, which said that care guidelines were being instituted in order to provide consistent and quality care that maintains the patient’s safety when seen by providers who may not know the patient well. The guidelines are as follows: The patient would not receive IV narcotics in the ED unless there is a medical condition unrelated to chronic pain. The ED should not be used for routine medical care or management of chronic pain, but the physician with the patient would help set up more frequent clinic visits. The ED or inpatient physicians would not fill orders for oral narcotics at discharge. The patient’s outpatient regimen should be used for chronic pain or exacerbations of chronic pain, and IV Benadryl or IV benzodiazepines should not be used for pain control.

The physician should offer substance-abuse treatment programs when appropriate, the care plan continued. Repeated imaging studies such as CT scans were discouraged unless new pathology was suggested by an exam, vital signs, and/or screening labs, because repeated imaging exposes the patient to radiation. The patient should not attempt to obtain narcotic prescriptions from anyone other than the designated primary care provider. If the patient does not follow the rules described in the care plan, the medical group "would have to consider releasing you from our care, since noncompliance leads us to being unable to care for you safely and appropriately."

Dr. Hilger cited a New Yorker magazine article by Dr. Atul Gawande of Harvard University describing the benefits of coordinating care for the most chronically expensive patients. The use of care plans promotes consistency in care; reinforces goals and expectations; empowers patients to take steps toward positive change; fosters patient trust; increases use of primary care; and decreases hospitalizations, readmissions, and total costs, the article suggests.

"We didn’t invent this" idea of care plans, Dr. Hilger said. Many hospitals are experimenting with elements of specialized care plans, but research so far has been limited mainly to EDs, he added. Specialized care plans are becoming popular for the less than 1% of patients with high rates of medically unnecessary emergency visits and admissions.

Dr. Hilger reported having no financial disclosures.