Many patients seek treatment from emergency services for non-urgent (often chronic) conditions that could be handled better in other care settings. Patients do so for a variety of reasons, ranging from convenience to barriers in accessing primary care. This situation results in higher costs of care. Also, patients often receive fragmented care and inadequate management of underlying medical, behavioral, and psychosocial needs. Moreover, emergency services become overburdened and struggle to provide services for patients with urgent and emergent needs.
With the support of the Agency for Healthcare Research and Quality (AHRQ) Innovations Exchange, the Reducing Non-Urgent Emergency Services Learning Community (ES LC) formed in October 2014 with the goal of addressing frequent and non-urgent use of emergency services in the Detroit metropolitan area. The ES LC assembled a coalition of private and public stakeholders that cross-cut five different service systems in Detroit, including primary care, emergency services, mental health, substance abuse, and social services. Receiving guidance and technical support from local- and state-level stakeholders, experts, and innovators, the ES LC adapted and implemented strategies from a cluster of select innovations from the Innovations Exchange collection.
Learning Community Aims
The ES LC had three primary aims:
- Aim #1: Identify non-urgent/high utilizers of emergency services.
- Aim #2: Improve coordination between emergency medical services, primary care, behavioral health, and social services.
- Aim #3: Appropriately reduce non-urgent/high utilization of emergency services by applying effective service delivery models to meet the target population’s needs.
Activities and Accomplishments
During its two-year operation under the Innovations Exchange, the ES LC held virtual monthly membership meetings, core team and subcommittee meetings, and two in-person meetings in Detroit, all with the purpose of developing and implementing a protocol to address the ES LC aims. After reviewing innovative strategies designed to reduce frequent and non-urgent use of emergency services, ES LC members considered the feasibility of adapting innovations based on available resources, as well as contextual and political factors in the Detroit community.
The Innovations Exchange profiles that informed the work of the ES LC included:
Throughout the process of protocol development, the ES LC consulted local and national experts who have done similar work to identify and appropriately support frequent and non-urgent users of emergency services. These experts indicated that providing supports to the most frequent 911 callers has been a particularly effective strategy for reducing 911 call volumes. The ES LC also consulted with the Detroit East Medical Control Authority, Detroit city attorneys, and State emergency medical services (EMS) representatives to obtain their support of the protocol and consider any pertinent legal or operational issues.
In May 2015, ES LC members developed a protocol that outlined how the stakeholder groups would work together across systems and agencies to address the ES LC’s aims. The protocol has multiple components, which include:
- Enabling and encouraging Detroit emergency medical services (EMS) personnel to make real-time referrals through the EMS electronic system to two community organizations: the Institute for Population Health (IPH) and the Detroit Area Agency on Aging (DAAA). These referrals are specifically for patients who have non-urgent needs and/or could benefit from additional health care or social support services.
- Clients aged 60 or older are referred to DAAA, while clients under 60 are referred to IPH.
- DAAA and IPH follow up with the patients identified to assess additional physical health, behavioral health, and social needs, and provide appropriate support and referrals to community resources.
- Establishing a process to identify and work with the top 25 EMS users (super-users) that includes the following components:
- Handoff from EMS to a Voices of Detroit Initiative (VODI) care coordinator
- Completion of a comprehensive assessment and development of an accompanying plan for crisis stabilization
- Regular weekly follow-up
- Monthly review
- Graduation/program completion
- Identifying and intervening at local “hot spot” locations where there is significant EMS activity.
- Interventions include placing clinical staff on-site at homeless shelters to address clients’ non-urgent medical needs, and rapidly enrolling senior housing facility residents into appropriate DAAA programs.
Through April 2016, EMS had made 288 referrals to IPH and DAAA (96 and 192, respectively). The referral process built off a pilot project whereby DAAA received EMS referrals, and the referral process was entirely new for IPH. The client needs identified by IPH and DAAA have included assistance with social and clinical services, such as dental care, maternal child health programs, utilities, transportation, nutrition, household maintenance, health insurance, and home visits.
On-site interventions focused on addressing non-urgent health care needs and providing appropriate social support services are in place at select homeless shelters and senior housing facilities that had been identified as ‘hot spot’ locations. The top hot spot location, Neighborhood Service Organization (NSO) Tumaini Center, has joined with Detroit Receiving Hospital to pilot an innovation offering on-site health care services at the Tumaini Center three days a week through a nurse practitioner. Preliminary data show that fewer 911 calls are received when these services are offered; there were 46 calls to 911 when clinical staff were available compared with 181 calls to 911 when clinical staff were unavailable. The ES LC developed a proposal to seek additional funding from local foundations to expand this program, and is considering similar programs at other hot spot locations.
Beginning in May 2016, VODI began systematically reviewing and outreaching to the top 25 super-users, and information provided by DAAA indicates that there were no super-users who are age 60 or older between May 2015 and July 2016. Though formal analyses were not conducted on this data, DAAA suggests that this finding reflects that these individuals’ health and social needs were met.
The work of the ES LC is unique in that it crosses community systems as well as health care organizations. As noted, ES LC members include leaders from five different service systems. The leadership team found that it was important to work with members from each system independently to identify their individual priorities and help the ES LC make connections on common needs and goals. Given that these systems’ needs are dynamic, and in some cases fluctuate with the political climate, reconciling the priorities of stakeholder organizations was an important process that required significant time and ongoing attention.
The ES LC experienced some challenges related to the implementation of the protocol. A high percentage of EMS referrals had inaccurate or incomplete contact information, so service agencies were not able to reach these individuals. Even when the service agencies did have complete and accurate contact information, they found individuals were minimally responsive to outreach attempts. Innovations Exchange innovators reported that these are common challenges, and recommended strategies such as enhancing data sharing initiatives and improving the handoff process. The ES LC focused efforts on executing these recommendations; however, progress requires coordination among multiple organizations and stakeholder groups.
Tracking process and outcomes data on the impact of the protocol implementation presented another challenge. Since the protocol components are spread across multiple agencies, there are many disparate data sources, and the ES LC’s efforts to implement a universal data collection and measurement process were limited due to differences in organizational processes and resources. Similarly, the ES LC experienced difficulty obtaining data from select partners. ES LC members pursued multiple options to address this challenge. A subgroup is currently developing an analysis plan and process for evaluating the effectiveness of the ES LC’s protocol.
The ES LC champions and members have expressed a commitment to continue the ES LC’s work and have been actively pursuing avenues for sustaining the protocol interventions, as well as the administrative infrastructure of the ES LC. Key activities are described below.
- Partnering with Detroit East Medical Control Authority (DEMCA). DEMCA is an entity that oversees EMS in Detroit and comprises hospitals in Detroit and surrounding areas. The ES LC is pursuing a more formal partnership with DEMCA since the ES LC’s priority topics align with the goals and activities of DEMCA. Additionally, DEMCA has access to EMS data and has established mechanisms for data sharing that may enable the LC to more effectively contact patients (by ensuring complete and accurate patient information), track outcomes, and identify patients who could benefit from additional support. The plan is to include representatives from ES LC member organizations on a DEMCA advisory board and create a DEMCA committee focused specifically on the ES LC’s work.
- Developing a data analysis plan. DEMCA, VODI, and the Altarum Institute are working together to develop an analysis plan to evaluate the impact of the protocol, including EMS referrals to social service agencies and any associated cost savings resulting from decreases in health care utilization.
- Securing funding to continue clinical and service delivery activities. As noted above, the protocol includes interventions targeting 1) patients referred by EMS, 2) the 25 super-users of 911 services, and 3) individuals at hot spot locations. ES LC members continue to explore whether local public entities or foundations could provide funding or resources to help support these activities.