Coordinated, Intensive Medical, Social, and Behavioral Health Services Improve Outcomes and Reduce Utilization for Frequent Emergency Department Users
Coordinated, Intensive Medical, Social, and Behavioral Health Services Improve Outcomes and Reduce Utilization for Frequent Emergency Department Users
The Center for Integrative Management at Spectrum Health provides, manages, or coordinates intensive, concurrent medical and behavioral health care, addiction services, and social services for frequent emergency department users in Grand Rapids, Michigan. Provided in an easily accessible location for patients, services include a 4-hour intake visit, ongoing assessment and management through frequent clinic visits, round-the-clock access to providers, linkages to needed social services, and eventual transition to a primary care medical home once patients have stabilized. The program also provides an up-to-date care guide to local emergency department staff, helping them care for any participating patient who presents at their facility. The program has led to improvements in patient outcomes (severity of depression, functional status, levels of pain and anxiety, and drug use), which in turn have generated reductions in health system use and hospital charges and high levels of patient satisfaction.
Date First Implemented
Many emergency departments (EDs), especially those in urban areas, face the problem of frequent users who account for a disproportionate share of visits. These individuals often present with myriad chronic medical, behavioral, psychosocial, and substance abuse problems that cannot be addressed by ED staff. However, because these individuals typically face a multitude of barriers in accessing other providers, the ED becomes their “provider of choice.”
- A few heavy ED users: A relatively small number of ED users often account for a disproportionate share of visits and costs. In a study of 18 urban hospitals, 3.1 percent of ED users accounted for 16.5 percent of visits.1 Every year, the EDs at Spectrum Health's 2 largest hospitals—Butterworth Hospital and Blodgett Hospital—treat approximately 1,000 patients who visit the ED at least 10 times annually; in total, this relatively small number of patients accounts for 20,000 ED visits and $54 million in costs each year.
- Often for nonurgent needs that ED cannot address: Frequent ED users typically present with a variety of chronic medical conditions, chronic pain, or mental health and psychosocial issues, including substance abuse and addiction issues.2 , 3 At Spectrum Health, high users tend to have complex medical and mental illnesses, including psychiatric illnesses, chronic pain, or addiction.4 Most ED physicians do not have the time or knowledge to evaluate and manage these complex patients but also have few if any options for referring patients to appropriate treatment programs. As a result, these patients continue to return to the ED as their provider of choice.
Description of the Innovative Activity
The Center for Integrative Management at Spectrum Health provides, manages, or coordinates intensive, concurrent medical and behavioral health care, addiction services, and social services for frequent ED users in Grand Rapids, MI. Provided in an easily accessible location for patients, services include a 4-hour intake visit, ongoing assessment and management through frequent clinic visits, round-the-clock access to providers, linkages to needed social services, and eventual transition to a primary care medical home once patients have stabilized. The program also provides an up-to-date care guide to local ED staff, helping them care for any participating patient who presents at their facility. Key program elements include the following:
- Identifying and enrolling frequent ED users: Initially, program staff searched the Spectrum electronic medical record (EMR) to identify 100 patients who visited the ED more than 10 times a year. Staff called these patients to invite them to participate, with 94 agreeing to do so. On an ongoing basis, the program receives referrals from physicians at area EDs, with program staff reviewing the EMR to evaluate referred patients' past use of the health system and the likelihood of future utilization. The program now serves approximately 400 to 500 patients at any given time, and enrolls roughly 400 new patients a year. As of March 2013, the program had identified approximately 2,100 high ED users in its service area, which has a population of roughly 1 million.
- Intensive intake visit to assess risk: Patients initially undergo a 4-hour intake visit at Spectrum's Center for Integrative Management, during which a physician provides an extended medical evaluation and a licensed master social worker (LMSW) provides a behavioral health evaluation, including assessing for substance use and addiction. These providers gather comprehensive information about patient demographics, health-related behaviors, medical and family history, current medical problems, past history of trauma, mental health and psychosocial needs, and medication use, including any diagnostic tests and treatments entered into the EMR. During this visit, patients also receive general information outlining the practice's services and a schedule of future visits (more details on these visits appear below). Based on this assessment, center staff assign the patient a score and associated level of care: I, II, or III, with III requiring the most intensive services.
- Fixed payment for Spectrum plan enrollees: Spectrum's in-house health plan (Priority Health) pays the Center a fixed, bundled payment for each plan member enrolled in the program, with the amount varying by the assigned level of care—$1,000 for level 1, $2,000 for level 2, and $3,000 for level 3. These fees cover all services until the time the patient is discharged from the program. (The Funding Sources section provides additional information on how other payers pay for Center services.)
- Frequent, concurrent services at convenient location: The Center is located in downtown Grand Rapids near three bus lines and across the street from a large federally qualified health center. Physicians, physician assistants, and LMSWs see patients on a weekly basis for the first 4 or 5 weeks after enrollment, and then every other week thereafter to identify and subsequently address medical, behavioral health, and social service needs. The physicians and LMSWs meet formally every morning to discuss the day's patients and talk informally throughout the day to confer on patient care as needed. Services include enhanced medical management, intensive psychiatric evaluation and treatment, social service linkages, and 24-hour telephone-based support, as outlined below:
- Medical care and management: With the support of a physician assistant, the doctor conducts a full diagnostic evaluation and provides, manages, and coordinates ongoing, intensive medical care, making referrals to specialists as needed.
- Psychiatric and behavioral health services: During each visit, an LMSW conducts an indepth patient evaluation to assess behavioral health needs, and provides appropriate mental health and addiction services, with care guided by customized, patient-centered treatment plans. When necessary, psychiatric consultations are conducted by telephone.
- Links to social services: An LMSW intern identifies and arranges links to all needed social services, such as assistance with housing, transportation, food, and medical insurance.
- Round-the-clock telephone access to staff: Patients have telephone access to Center staff 24 hours a day, 7 days a week, with the physician and physician assistant alternating the call schedule. Whenever a patient calls, the clinicians determine if a true emergency exists, and provide additional support and assistance (e.g., with managing anxiety) as necessary. Although call volume tends to be quite high, these calls often become a replacement for more expensive ED visits.
- Care guide shared with all local EDs: All services, assessments, and treatment responses are documented on an ongoing basis in a care guide that serves as an up-to-date record of treatments (including those that failed) and general information about the patient's needs. The guide is shared with all area EDs via electronic and paper-based communication, helping ED-based staff understand how to approach the patient if he or she presents to the ED. For example, if the patient has a borderline personality disorder, the guide recommends that two staff be present at all times during patient care, and in some cases may specify that the patient not receive any controlled substances.
- Smooth transition to primary care for stable patients: Patients who have stabilized can be transitioned to a primary care office. Patients are not considered eligible for a transfer until they have three successful visits with a primary care provider at the Center. These patients receive a “warm handoff” to primary care, with the Center physician discussing the patient's needs with the primary care physician. In many cases, the LMSW accompanies the patient to the first few primary care visits after the transition. In all cases, the LMSW conducts a followup call with the patient 6, 12, and 18 months after program discharge.
Context of the Innovation
Spectrum Health is a regional, not-for-profit health system in Michigan with 11 hospitals that collectively have approximately 2,000 licensed beds, a multispecialty medical group with 423 providers, and an in-house health plan known as Priority Health with 634,000 enrollees. Spectrum Health's 2 largest hospitals—Butterworth and Blodgett—together handle more than 150,000 adult ED visits each year.
In 2008, Dr. R. Corey Waller, an emergency medicine and addiction specialist, became concerned by the large, growing number of patients who regularly came to the ED with a wide array of medical, mental, and substance abuse problems. In a pilot study, he devoted a day each week to care for 30 of these heavy ED users; over a 1-year period, ED visits among these patients fell by 85 percent and associated hospital costs declined by $1 million. He shared these data with health system leaders and asked for support and funding for a more systematic program to serve high ED users, which ultimately led to the opening of the Center for Integrative Medicine.
The program has led to improvements in patient outcomes (severity of depression, functional status, levels of pain and anxiety, and drug use), which in turn have generated reductions in health system use and hospital charges and high levels of patient satisfaction.
- Better patient outcomes: In a review of 296 patients, the typical patient improved his or her depression score from severe to mild, experienced a 32-point increase in global assessment of function scores (with no patients experiencing declines), cut illicit drug use by one-half, and reduced prescription medication use by more than 50 percent. In addition, those with pain syndrome reduced their visual analog pain scale scores by 4.3 points (from 8.2 to 3.9), and 40 percent of smokers receiving cessation support at the Center quit smoking. Collectively, these improvements allowed these patients to graduate from the program and be transitioned to a primary care medical home.
- Less use, lower costs: The same 296 patients reduced their use of the health system (including ED visits and hospital admissions) by 45 percent after 3 months and by more than 65 percent after 6 months, with these lower levels of use being maintained or even declining further throughout the first year of participation. Over the course of the year, hospital admissions fell by 74 percent and ED visits by 64 percent, and hospital charges for the first 100 patients declined by $2.7 million, even after factoring in the operational costs associated with running the program.
- High satisfaction: Anecdotal reports show that participating patients are highly satisfied with the program and believe it has improved their functionality and quality of life.
Planning and Development Process
Selected steps included the following:
- Developing business plan: Dr. Waller developed a business plan based on the results of the pilot test, and presented it to Spectrum Health's senior leaders for approval.
- Obtaining training: Dr. Waller obtained training and certification in addiction treatment and pain medicine.
- Partnering with behavioral health providers: Spectrum Health arranged a partnership with Network180, a local mental health and substance abuse treatment center, to provide behavioral health clinicians to the Center (see the Resources section for more information).
- Finding convenient location for patients: Spectrum Health identified a building to house the Center that would be convenient for patients to access care.
- Amending EMR: Information technology staff at Spectrum Health amended the EMR to include new fields and notes for Center staff to document patient care.
- Expanding coverage: The Center initially began seeing ED patients from Butterworth Hospital and Blodgett Hospital but eventually expanded to serve all EDs in the Grand Rapids area.
Resources Used and Skills Needed
- Staffing: The program includes a physician medical director, physician assistant, office manager, four medical assistants, two LMSWs, and LMSW interns. Employees of Network180 are LMSWs trained in cognitive behavioral therapy, motivational therapy, and other evidence-based mental health interventions.
- Costs: Annual operating costs total $860,000 and consist of clinic overhead and salary/benefits for all team members except the LMSWs (who are paid for their services by the state; see Funding Sources section for more details) and the interns, who attend a graduate program at a local university and provide services for free as part of a mandated clinical rotation. These operational costs to the health system are more than offset by the decline in patient costs by avoiding treatment in the ED. As noted previously, 1-year hospital charges for a subset of only 100 patients who were treated through the program declined by $2.7 million, even after factoring in the costs of the program.
As noted, Priority Health pays a per-patient bundled fee for participants enrolled in the plan based on their level of risk. Program leaders are currently in discussions with three other payers about using the same bundled payment structure for their enrollees. At present, Network180 bills these and other private and commercial insurers for services delivered to their enrollees. Network180 receives block funds from the Michigan Medicaid program to provide mental health and substance abuse treatment at the Center to Medicaid and uninsured patients in the county.
Getting Started with This Innovation
- Provide concurrent, integrated care: To care effectively for high ED users, services should include the concurrent provision of medical and behavioral health care, addiction services, and social services.
- View all team members as equal: Each team member should have an equal say in the care of the patient. For example, if the LMSW highlights a behavioral health or social services problem as the primary concern for the patient, the physician should be willing to temporarily hold off on a proposed medical intervention until the patient's other issues have been addressed. This approach may initially be difficult for physicians to accept, but they usually realize fairly quickly that the provision of medical care tends to be futile if other areas of the patient's life remain unstable.
- Expect challenges in identifying medical homes: Many primary care practices may be unwilling to accept these challenging patients, even after they have stabilized. To address this problem, the Center physician emphasizes that these patients are in fact stable, that the Center is not qualified to provide primary care and chronic disease management to them, that Center staff remain accessible around the clock for support, and that the Center will resume care for the patient if necessary.
- House services in convenient, standalone location: Find a separate, services should be offered at a convenient location and not on hospital grounds, because the goal is to convince patients to stop going to the hospital and ED and instead come to a community-based clinic.
Sustaining This Innovation
- Develop fee schedule for services: Unlike grant funding, service-based payments ensure a sustainable funding source for the program.
- Monitor and address staff morale issues: Serving this population of patients can be extremely difficult, as patients often become angry and even abusive. Consequently, it becomes necessary to monitor staff morale on an ongoing basis and take steps to make their jobs more manageable. For example, the four medical assistants at the Center have been cross-trained for different tasks, and they rotate responsibilities so that each spends 1 week each month on tasks that do not involve direct patient contact. This rotation helps them maintain their empathy when they do work with patients.
- Develop mechanisms to share information with area hospitals: This program works best when multiple hospitals participate, thus providing multiple referral sources (which helps promote financial sustainability) and allowing staff in all area EDs to be aware of participating patients' care guides. The Center is currently developing mechanisms to share more information with staff at area hospitals. For example, it is working with others to develop a Health Insurance Portability and Accountability Act–compliant, countywide form to facilitate the sharing of medical information across all hospitals in the county. The Center is also developing an arrangement with an existing health information exchange to facilitate sharing of the patient care guides.
Contact the Innovator
Note: Innovator contact information is no longer being updated and may not be current.
R. Corey Waller, MD
Center for Integrative Medicine
Spectrum Health Medical Group
75 Sheldon SE, Suite 100
Grand Rapids, MI 49503
Phone: (616) 391-6120
Dr. Waller reported having no financial interests or business/professional affiliations relevant to the work described in the profile.
Information about the Center for Integrative Medicine is available at: http://www.shmg.org/cim.
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Lubell J. “Frequent flyers” not seen as abusing emergency departments. Am Med News. 2012 Oct. Available at: http://www.ama-assn.org/amednews/2012/10/22/gvsb1022.htm.
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Spectrum Health Medical Group. Center for Integrative Medicine. Available at: http://www.shmg.org/cim.