Case management for frequent emergency department users: no longer a question of if but when, where and how

Abstract

Ten years ago, an editorial entitled “Frequent Users of Emergency Department Services: Gaps in Knowledge and a Proposed Research Agenda” was written by Pines and colleagues describing the evidence surrounding frequent emergency department (ED) use at the time, while proposing ways to advance the field in the years ahead [1]. Citing a handful of studies, Pines et al. concluded that ED-based interventions aimed at reducing frequent ED use showed promise but voiced concern about the generalizability and feasibility of these interventions, highlighting a need for further research. Ten years on, the field of frequent ED use, generally classified as more than 4 ED visits in a year [2], has evolved considerably. Specifically, the evidence supporting ED-based, as well as primary care-based, interventions aimed at frequent users of the ED has grown dramatically thus presenting a unique opportunity to reflect on what we know now and where the field is heading in 2020 and beyond. Since 2011, at least eight reviews have been published that summarize the evolving evidence supporting interventions aimed at reducing ED use amongst frequent users [3–10]. What is notable is the emergence of case management as the most widely discussed primary care and ED-based intervention. Other interventions described include individualized care plans, diversion strategies to non-urgent care, social work home visits, and models of patient navigation, but none have garnered the same attention as case management over the years [5, 10, 11]. Case management, defined as “a collaborative approach to ensure, coordinate and integrate care and services for patients, in which a case manager evaluates, plans, implements, coordinates, and prioritizes services on the basis of patient’s needs”[11], has gained global recognition as an intervention that can reduce ED visits and related healthcare costs amongst frequent users [3, 6, 11]. Reductions in ED costs of 26–45% and inpatient costs of up to 67% have been cited [3, 4, 6]. When costs of implementing the case management intervention are considered, total hospital expenditures appear similar to usual care but with improved clinical and social outcomes [3, 4, 6]. Other cited benefits include improved patient quality of life and patient satisfaction while also helping achieve more equitable healthcare by reducing barriers to care for frequent ED users who tend to have higher rates of psychiatric and medical comorbidities, higher rates of social isolation, and less financial resources [1, 11]. By employing a case manager to coordinate and synchronize care across diverse care settings and amongst multiple care providers, addressing both the medical and social needs of these patients, case management interventions can fill gaps in care which no individual care setting (whether ED or primary care) could accomplish alone. What is more, the emergence of case management as the most widely supported intervention for frequent users of the ED appears largely consistent despite differences in study inclusion criterion across published reviews. Whether focused on general adult frequent users, adults with chronic diseases, or individuals facing homelessness or other * Mary Malebranche [email protected]