Kelly M. Doran

What drives frequent emergency department use in an integrated health system? National data from the Veterans Health Administration.

STUDY OBJECTIVE There is widespread concern about patients with frequent emergency department (ED) use. We identify sociodemographic and clinical factors most strongly associated with frequent ED use within the Veterans Health Administration (VHA) nationally. METHODS We conducted a cross-sectional analysis of national VHA databases (N=5,531,379) in 2010. The primary outcome measure was the number of VHA ED visits categorized into 6 frequency levels. RESULTS In 2010, 4,600,667 (83.2%) VHA patients had no ED visit, whereas 493,391 (8.9%) had 1 visit, 356,258 (6.4%) had 2 to 4 visits, 70,741 (1.3%) had 5 to 10 visits, 9,705 (0.2%) had 11 to 25 visits, and 617 (0.01%) had greater than 25 visits. Increasing ED use frequency was associated with homelessness, medical diagnoses, substance abuse and psychiatric diagnoses, receipt of psychotropic and opioid prescriptions, and more frequent use of outpatient medical and mental health services. In multivariable analyses, factors most strongly associated with all levels of ED use were schizophrenia (odds ratio [OR] range 1.44 [95% confidence interval {CI} 1.41 to 1.47] to 6.86 [95% CI 5.55 to 8.48] across categories of increasing ED use), homelessness (OR range 1.41 [95% CI 1.38 to 1.43] to 6.60 [95% CI 5.36 to 8.12]), opioid prescriptions filled (OR range 2.09 [95% CI 2.07 to 2.10] to 5.08 [95% CI 4.16 to 6.19]), and heart failure (OR range 1.64 [95% CI 1.63 to 1.66] to 3.53 [95% CI 2.64 to 4.72]). CONCLUSION Frequent ED use occurs even in a coordinated health care system that provides ready access to outpatient care. Frequent ED users are characterized by traits that represent high levels of psychosocial and medical needs. The correlates we identified for frequent ED use were consistent across multiple distinct levels of ED use.

An intervention to improve care and reduce costs for high-risk patients with frequent hospital admissions: a pilot study

BackgroundA small percentage of high-risk patients accounts for a large proportion of Medicaid spending in the United States, which has become an urgent policy issue. Our objective was to pilot a novel patient-centered intervention for high-risk patients with frequent hospital admissions to determine its potential to improve care and reduce costs.MethodsCommunity and hospital-based care management and coordination intervention with pre-post analysis of health care utilization. We enrolled Medicaid fee-for-service patients aged 18-64 who were admitted to an urban public hospital and identified as being at high risk for hospital readmission by a validated predictive algorithm. Enrolled patients were evaluated using qualitative and quantitative interview techniques to identify needs such as transportation to/advocacy during medical appointments, mental health/substance use treatment, and home visits. A community housing partner initiated housing applications in-hospital for homeless patients. Care managers facilitated appropriate discharge plans then worked closely with patients in the community using a harm reduction approach.ResultsNineteen patients were enrolled; all were male, 18/19 were substance users, and 17/19 were homeless. Patients had a total of 64 inpatient admissions in the 12 months before the intervention, versus 40 in the following 12 months, a 37.5% reduction. Most patients (73.3%) had fewer inpatient admissions in the year after the intervention compared to the prior year. Overall ED visits also decreased after study enrollment, while outpatient clinic visits increased. Yearly study hospital Medicaid reimbursements fell an average of

The revolving hospital door: hospital readmissions among patients who are homeless.

16,383 per patient.ConclusionsA pilot intervention for high-cost patients shows promising results for health services usage. We are currently expanding our model to serve more patients at additional hospitals to see if the pilots success can be replicated.Trial registrationClinicaltrials.gov Identifier: NCT01292096

Developing a novel poverty in healthcare curriculum for medical students at the University of Michigan Medical School

Background:National attention is increasingly focused on hospital readmissions. Little prior research has examined readmissions among patients who are homeless. Objective:The aim of the study was to determine 30-day hospital readmission rates among patients who are homeless and examine factors associated with hospital readmissions in this population. Methods:We conducted a retrospective chart review of patients who were homeless and hospitalized at a single urban hospital from May–August 2012. Homelessness was identified by an electronic medical record flag and confirmed by manual chart review. The primary outcome was all-cause hospital readmission to the study hospital within 30 days of hospital discharge. Patient-level and hospitalization-level factors associated with risk for readmission were examined using generalized estimating equations. Results:There were 113 unique patients who were homeless and admitted to the hospital a total of 266 times during the study period. The mean age was 49 years, 27.4% of patients were women, and 75.2% had Medicaid. Half (50.8%) of all hospitalizations resulted in a 30-day hospital inpatient readmission and 70.3% resulted in either an inpatient readmission, observation status stay, or emergency department visit within 30 days of hospital discharge. Most readmissions occurred early after hospital discharge (53.9% within 1 week, 74.8% within 2 weeks). Discharge to the streets or shelter versus other living situations was associated with increased risk for readmission in multivariable analyses. Conclusions:Patients who were homeless had strikingly high 30-day hospital readmission rates. These findings suggest the urgent need for further research and interventions to improve postdischarge care for patients who are homeless.

Medical Respite Programs for Homeless Patients: A Systematic Review

Nearly 90 million Americans live below 200% of the federal poverty threshold. The links between lower socioeconomic status and poor health are clear, and all physicians face the resulting challenges in patient care. Current medical school curricula do not adequately prepare students to address this issue despite recommendations from the Association of American Medical Colleges and the Institute of Medicine. In response, students and faculty at the University of Michigan Medical Center established the Poverty in Healthcare curriculum, which encompasses required learning experiences spanning all four years of undergraduate medical education. This article describes the design and implementation of this curriculum. The authors provide thorough descriptions of the individual learning experiences, including community site visits, longitudinal cases, mini-electives, and family centered experiences. The authors also discuss the history, costs, challenges, and evaluation process related to the Poverty in Healthcare curriculum, including issues specifically related to medical students’ involvement in developing and implementing the curriculum. This information may be used as a guide for other medical schools in the development of curricula to address this current gap in medical student education.

New media use by patients who are homeless: the potential of mHealth to build connectivity.

Medical respite programs provide care to homeless patients who are too sick to be on the streets or in a traditional shelter, but not sick enough to warrant inpatient hospitalization. They are designed to improve the health of homeless patients while also decreasing costly hospital use. Although there is increasing interest in implementing respite programs, there has been no prior systematic review of their effectiveness. We conducted a comprehensive search for studies of medical respite program outcomes in multiple biomedical and sociological databases, and the grey literature. Thirteen articles met inclusion criteria. The articles were heterogeneous in methods, study quality, inclusion of a comparison group, and outcomes examined. Available evidence showed that medical respite programs reduced future hospital admissions, inpatient days, and hospital readmissions. They also resulted in improved housing outcomes. Results for emergency department use and costs were mixed but promising. Future research utilizing adequate comparison groups is needed.

Emergency department visits for heart failure and subsequent hospitalization or observation unit admission

Background Patients experiencing homelessness represent a disproportionate share of emergency department (ED) visits due to poor access to primary care and high levels of unmet health care needs. This is in part due to the difficulty of communicating and following up with patients who are experiencing homelessness. Objective To determine the prevalence and types of “new media” use among ED patients who experience homelessness. Methods This was a cross-sectional observational study with sequential enrolling of patients from three emergency departments 24/7 for 6 weeks. In total, 5788 ED patients were enrolled, of whom 249 experienced homelessness. Analyses included descriptive statistics, and unadjusted and adjusted odds ratios. Results 70.7% (176/249) of patients experiencing homelessness own cell phones compared to 85.90% (4758/5539) of patients in stable housing (P=.001) with the former more likely to own Androids, 70% (53/76) versus 43.89% (1064/2424), and the latter more likely to have iPhones, 44.55% (1080/2424) versus 17% (13/76) (P=.001). There is no significant difference in new media use, modality, or frequency for both groups; however, there is a difference in contract plan with 50.02% (2380/4758) of stably housed patients having unlimited minutes versus 37.5% (66/176) of homeless patients. 19.78% (941/4758) of patients in stable housing have pay-as-you-go plans versus 33.0% (58/176) of homeless patients (P=.001). Patients experiencing homelessness are more likely to want health information on alcohol/substance abuse, mental health, domestic violence, pregnancy and smoking cessation. Conclusions This study is unique in its characterization of new media ownership and use among ED patients experiencing homelessness. New media is a powerful tool to connect patients experiencing homelessness to health care.

An Intervention Connecting Low-Acuity Emergency Department Patients With Primary Care: Effect on Future Primary Care Linkage

BACKGROUND Treatment of acute heart failure in the emergency department (ED) or observation unit is an alternative to hospitalization. Both ED management and observation unit management have been associated with reduced costs and may be used to avoid penalties related to rehospitalizations. The purpose of this study was to examine trends in ED visits for heart failure and disposition following such visits. METHODS We used the National Hospital Ambulatory Medical Care Survey, a representative sample of ED visits in the United States, to estimate rates and characteristics of ED visits for heart failure between 2002 and 2010. The primary outcome was the discharge disposition from the ED. Regression models were fit to estimate trends and predictors of hospitalization and admission to an observation unit. RESULTS The number of ED visits for heart failure remained stable over the period, from 914,739 in 2002 to 848,634 in 2010 (annual change -0.7%, 95% CI -3.7% to +2.5%). Of these visits, 74.2% led to hospitalization, wheras 3.1% led to observation unit admission. The likelihood of hospitalization did not change during the period (adjusted prevalence ratio 1.00, 95% CI 0.99-1.01 for each additional year), whereas admission to the observation unit increased annually (adjusted prevalence ratio 1.12, 95% CI 1.01-1.25). We observed significant regional differences in likelihood of hospitalization and observation admission. CONCLUSIONS The number of ED visits for heart failure and the high proportion of ED visits with subsequent inpatient hospitalization have not changed in the last decade. Opportunities may exist to reduce hospitalizations by increasing short-term management of heart failure in the ED or observation unit.

Navigating the Boundaries of Emergency Department Care: Addressing the Medical and Social Needs of Patients Who Are Homeless

STUDY OBJECTIVE Our objective is to determine whether a point-of-care intervention that navigates willing, low-acuity patients from the emergency department (ED) to a Primary Care Clinic will increase future primary care follow-up. METHODS We conducted a quasi-experimental trial at an urban safety net hospital. Adults presenting to the ED for select low-acuity problems were eligible. Patients were excluded if arriving by emergency medical services, if febrile, or if the triage nurse believed they required ED care. We enrolled 965 patients. Navigators escorted a subset of willing participants to the Primary Care Clinic (in the same hospital complex), where they were assigned a personal physician, were given an overview of clinic services, and received same-day clinic care. The primary outcome was Primary Care Clinic follow-up within 1 year of the index ED visit among patients having no previous primary care provider. RESULTS In the bivariate intention-to-treat analysis, 50.3% of intervention group patients versus 36.9% of control group patients with no previous primary care provider had at least 1 Primary Care Clinic follow-up visit in the year after the intervention. In the multivariable analysis, the absolute difference in having at least 1 Primary Care Clinic follow-up for the intervention group compared with the control group was 9.3% (95% confidence interval 2.2% to 16.3%). There was no significant difference in the number of future ED visits. CONCLUSION A point-of-care intervention offering low-acuity ED patients the opportunity to alternatively be treated at the hospitals Primary Care Clinic resulted in increased future primary care follow-up compared with standard ED referral practices.

Emergency Department Visits for Homelessness or Inadequate Housing in New York City before and after Hurricane Sandy.

OBJECTIVES We sought to understand interpersonal and systems-level factors relevant to delivering health care to emergency department (ED) patients who are homeless. METHODS We conducted semistructured interviews with emergency medicine residents from 2 residency programs, 1 in New York City and 1 in a medium-sized northeastern city, from February to September 2012. A team of researchers reviewed transcripts independently and coded text segments using a grounded theory approach. They reconciled differences in code interpretations and generated themes inductively. Data collection and analysis occurred iteratively, and interviews continued until theoretical saturation was achieved. RESULTS From 23 interviews, 3 key themes emerged: (1) use of pattern recognition in identifying and treating patients who are homeless, (2) variations from standard ED care for patients who are homeless, and (3) tensions in navigating the boundaries of ED social care. CONCLUSIONS Our study revealed practical and philosophical tensions in providing social care to patients in the ED who are homeless. Screening for homelessness in the ED and admission practices for patients who are homeless are important areas for future research and intervention with implications for health care costs and patient outcomes.