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:
In the area of Public Health and Injury Prevention, our country earned a C. The criterion evaluates national performance on:
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:
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: