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ER Diversion Project: Reducing Unnecessary ER Visits

Wednesday, February 12, 2014   (0 Comments)
Posted by: Joy Ingram
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by Rebekah Scharf, RN, BSN, Clinical Care Coordinator, Community Health Center of Snohomish County, Edmonds Medical Clinic


Community Health Center of Snohomish County (CHC), Edmonds received grant funding in 2011 from the Verdant Health Commission to develop the Emergency Room Diversion Project. The aim of the Emergency Room Diversion Project is to reduce low acuity, unnecessary Emergency Room (ER) visits. A Registered Nurse was hired to take on the position of Clinical Care Coordinator for this project. 


In 2011 Washington state proposed to limit the number of non-emergent ER visits that would be covered. Lawsuits challenged this policy and in its place Washington ERs had to implement the “Seven Best Practices” to reduce unnecessary ER use in 2012[1] . All Washington ERs are now enrolled in the “Seven Best Practices” program. Examples of the program include: tracking ER visits with the Emergency Department Information Exchange (EDIE), monitoring substance use on the state’s Prescription Monitoring Program, educating patients on how to use appropriate sources of care, and creating care plans which includes narcotic guidelines[2]. The Emergency Room Diversion Project at CHC seeks to follow these practices from the ambulatory care setting in coordination with the hospital ER setting. 


A partnership was initiated with two local ERs, Swedish Edmonds and Swedish Mill Creek. Many patients go to the ER because they do not have a primary care provider (PCP). As a result of our partnership, these two ERs began referring more patients without a PCP to CHC. They started to display CHC brochures with access information and installed phones in the ER waiting rooms that connect directly with CHC’s Call Center for patients to easily schedule appointments. In the first two years of the project, 321 patients established care as referred by these ERs. We had hoped to receive the demographics on all patients referred to our clinic so we could contact those patients and invite them to establish care; however, the ERs have been unable to generate this type of report.


Another initial step in the project was figuring out how to identify and communicate CHC Edmonds patients who were seen in the ER. We were able to set up a daily email report with one of our hospital ER partners that informs us of CHC patients seen in their ER. However a setback we experienced in this was that the hospital went through a major change in their electronic health record system and it took a while to figure out a report that would actually work. Although this report is somewhat helpful, our actual goal is to get access to EDIE which will allow us to receive real time notifications when one of our high ER utilizers is seen in the ER. We are currently in the process of setting up this interface with the hospitals. Once completed we will receive notification of all CHC patients seen in the ER, meeting our established criteria, and can then begin a Level 1 or 2 Intervention.


A Level 1 Intervention is defined as an intervention for patients who visit the ER for a non-acute reason. This intervention informs the patient or guardian on the appropriate use of the primary care office, urgent care, and the ER. Materials developed include a refrigerator magnet with CHC nurse advice line numbers and an after-hour nurse advice information line. A letter is given outlining the importance of primary medical care as well as the services CHC offers which includes same day appointments reserved for urgent needs. Holly Hayes, CHC Edmonds Practice Manager, developed a handbook titled “How to Care for Your Sick Child.” This handbook highlights common childhood illnesses and injuries, basic home care information, and information on when to seek care. Thermometers were also purchased to give out to patients in need, to help with accurate home monitoring. The Level 1 Intervention also helps address any barriers in receiving comprehensive primary care with CHC. At the end of the second year of the project, 223 adult and 153 pediatric Level 1 Interventions had been completed.


A Level 2 Intervention occurs for patients who repeat use of the ER for non-urgent reasons despite having been through a Level I intervention. An important component of this intervention is collaborating with both the primary care provider and the patient to create a care plan. Until we have access to EDIE, we share care plans with the ER care coordinators to be uploaded into their EDIE site. During the second year of the program, new correspondence was made with several other hospital ER care coordinators who were eager to work with us to collaborate on patient care plans. A total of 13 adult and 6 pediatric Level 2 Interventions were completed by the end of the second year of the project. 


Another facet of the project was developed to help cover the cost of prescription medication for homeless patients. Homeless patients who are not able to afford their prescription medications frequently use the ER for short term refills or are seen for an exacerbation of a chronic condition due to lack of necessary medication. In the first two years of the project, 975 prescriptions were filled and thus unnecessary ER visits were avoided.


An additional component of the project has been reaching out to community organizations. Presentations have been done on CHC primary care services along with education regarding appropriate health care utilization. We have connected with multiple organizations and have reached almost 200 community residents. 


We have now entered the third and final year of the Emergency Room Diversion Project. This year, as mentioned earlier, we aim to obtain access to the EDIE site so we can have real time notification when high utilizer patients visit the ER. We aim to increase the number of community members reached through presentations and outreach. For homeless patients receiving prescription assistance, we are helping them find alternative prescription coverage. We are also in the process of developing a comprehensive brochure outlining the differences of primary care, urgent care, and the ER. The brochure is directed toward CHC patients and will include details about our nurse advice information line and local urgent care offices. Once complete, we hope to have the brochure translated into Spanish. Thus far, the Emergency Room Diversion Project has been a success and we continue to strive to reduce low acuity, unnecessary ER visits and improve the health of our patients.


[1] Kellermann AJ, Weinick RM. Emergency Departments, Medicaid Costs, and Access to Primary Care Understanding the Link. N Engl J Med 2012; 366:2141-2143


[2] ER is for Emergencies. (2013). Retrieved January 20, 2014, from https://www.wsma.org/ED-campaign#bestpractices

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