On Jan. 16, 2014, ACEP released the latest version of its National Report Card on the State of Emergency Medicine. The report rates both the nation and individual states in five areas:
- Access to Emergency Care
- Quality & Patient Safety Environment
- Medical Liability Environment
- Public Health & Injury Prevention
- Disaster Preparedness
In the area of Public Health and Injury Prevention, our country earned a C. The criterion evaluates national performance on:
- Traffic safety and drunk driving
- Fatal injury
- State health and injury prevention efforts
- Health risk factors
The report card discusses many steps lawmakers can take to improve population health (e.g., enacting stricter seatbelt laws and drunk driving penalties). However, when it comes to the other four factors, hospital emergency departments can also make a big difference.
Since 2011, I've served as program director of the West Los Angeles Homeless Patient Aligned Care Team (HPACT), which is a demonstration project of the VA Greater Los Angeles Healthcare System. By implementing a team-based model that addresses both the medical and social determinants of health, our EDs have been able to help homeless veterans — who represent some of our highest-cost, resource-intensive and complex patients — find a "medical home" that helps them to manage their diverse and unique healthcare needs. This has resulted in a decrease in ED visits and hospitalization, and an increase in engagement in mental health, substance abuse and housing programs (for the homeless veteran population that we treated in this model) as well as patient satisfaction scores in the 98th percentile.
While population health may be an unexpected new role for emergency physicians, these providers are uniquely positioned to make a difference. The ED is often the first point of contact for high-risk patients — those who are homeless, have substance abuse and mental health issues, lack access to primary care, or whose health care needs are not adequately addressed by traditional care models. As many of their underlying needs are left unmet, these patients are likely to return to the hospital over and over. Until a more proactive approach can be taken to address these needs, the “frequent flyer” population will continue to grow and strain our emergency care resources.
The West Los Angeles HPACT team seeks to provide patient-centered, comprehensive health solutions for homeless veterans by co-locating a primary care practice (based on the patient-centered medical home model) in our system's emergency department. On evenings and weekends (when other VA homeless services are limited), ED patients are screened by the triage nurse. When medically appropriate (non-urgent, generally ESI Level 4 and 5), those patients deemed homeless or at-risk for homelessness are given the option to be seen by the HPACT primary care team. (Often, they choose this option because it's faster than waiting for an ED physician.)
The patient is seen by a team of providers, which usually includes a medical provider, RN case manager, social worker, and when necessary, a mental health provider. Emphasis is placed on a patient-centered treatment plan that incorporates the social needs most germane to the homeless veteran population, including:
- Food security
- Preventative and primary medical care
- Pain management
- Treatment for mental health issues such as post-traumatic stress disorder and substance abuse issues
The HPACT model is based on the awareness that the social determinants of health are as important to consider as the traditional medical determinants. For example, it becomes increasingly difficult for a homeless veteran to adhere to a diabetes medication regimen when they don’t have a place to store the medication. And a homeless patient who's discharged from detox to the street is all too likely to relapse and return without appropriate case management and follow-up. This concept also extends to the non-veteran population. A child is unlikely to benefit long-term from asthma treatment if she's living in an apartment contaminated with toxic mold.
HPACT also recognizes the importance of a team approach to case management. Stopping the cycle of homelessness and ED overutilization often requires taking some time with patients to dig deeper into their histories and situations. Having a dedicated team available to coordinate care for appropriate, non-urgent cases allows emergency providers to focus more time on truly emergent patients.
Of course, not every hospital has a team in place to address the social side of care. But there are still many steps providers can take:
- Understand the needs in your patient population. Which groups of patients do you tend to see over and over in the emergency room? When do they usually show up? What keeps these patients from achieving better health?
- Identify resources. Many government and community organizations are available to assist at-risk patients. For example, if you're working with a veteran, the VA has a 24-hour hotline that is available to providers. VA outreach staff will actually come to your ED to determine your patient’s eligibility for services.
- Plan for effective transitions of care. Investing five extra minutes in a "warm handoff" can help prevent repeat visits down the road. This could take the form of calling the patient's primary care provider, referring the patient to a case manager or even offering the number of a helpful community organization.
- Recruit help. Ensure that case management services are available to physicians during the hours they're most needed (usually evenings and weekends when community clinics are closed). At HPACT, we've found that hiring a social worker case manager is a cost-effective way to fill this need.
- Leverage education and technology. Organizations such as HealthBegins are educating providers to be more conscious of the social determinants of health and implementing technology to make it easy for providers to access local resources and share these with patients via email or text.