Perspectives on The Acute Care Continuum gives a tip of the cap to Myles Riner, MD, for his prodigious year of blogging, including our number 2 most popular blog from 2012:
One of the topics that attracts a lot of attention when emergency physicians and those interested in ED practice management get together to discuss how emergency medicine can remain relevant in, and become integrated into, the new health care reform and value based purchasing paradigms, is the concept of care coordination. In theory, since the ED is linked to such a wide range of diagnostic testing resources, care facilities, and providers, and sits at the intersection of outpatient and inpatient care for many of the patients who are hospitalized: emergency physicians ought to be able to play an important role in the coordination of care, both for the acutely and for the chronically ill. In practice, many of the systems support structures that need to be in place to facilitate this role have often been ignored or neglected, or deferred on the assumption that they will be addressed with the adoption of the electronic medical record.
If emergency physicians and EDs are going to assume the role of master care coordinators (something that family physicians staffing the medical home might consider within THEIR scope), they are going to have to define this role carefully, invest in the systems and staffing to support it, and integrate the concept into everyday practice. Until now, few payers have been willing to pay for this service, and few hospitals and ED groups have been willing to invest significantly in the systems and staff to support it. Suddenly, care coordination is the latest buzzword, and the presumptive salvation for what is often perceived as a frequently too expensive and often inappropriately utilized drain on the health care system: the ED as poster-child for ‘the ‘failure of health care’.
What is ‘care coordination’? If we look specifically at the ‘acute care continuum’, which begins with first contact (some might even say illness and injury prevention) and ends with return to health, or at least to a chronic baseline status; it is certainly possible to imagine the emergency physician playing an important, and perhaps strategically optimal, role in recruiting, organizing, conducting, and tracking the resources that are needed to address the needs of the acutely ill or injured. EPs in fact do this every day, more than 100 million times a year, from the supervision of paramedics in the field to the decision to admit or discharge to the arranging of follow-up or return to work. Sometimes, this coordination service is done extremely well, but all too often, it’s an afterthought. Let’s just look at one aspect of care coordination: arranging follow-up for patients who are discharged from the ED to home, their condition stabilized, but in need of further care.
In the ideal world, the patient will have been thoroughly educated about their condition and the services they received in the ED, perhaps even through an iPad media presentation at the bedside. The patient would have received written after-care instructions, with a duplicate emailed to them, and if a prescription was needed, they might even have gotten a starter dose or two and the script electronically submitted to their preferred pharmacy, or filled right there in the ED. It goes without saying that the medication would be selected on the basis of the patient’s approved formulary, and checked against their usual meds for potential adverse interactions.
A summary of the patient’s ED care and treatment, and discharge instructions, would have been sent, by fax or email or via a shared EMR, to the patient’s primary care doctor, and if a referral to a specialist (in-network, of course) for further testing or treatment were indicated, the ED physician would have not only communicated with this physician, but also made an appointment for the patient (at a time that both specialist and patient could accommodate), with information about the specialist’s office address provided, and when necessary, transportation arranged. The patient would also have received a copy of the results of all tests performed in the ED, and the PCP or specialist would also be provided with these results in advance of the follow-up appointment. Home health care services, and social services, if needed, would also have been set up while the patient was still in the ED. The employer would have been notified in a worker’s comp related issue. Arrangements would have been made for the ER doc or nurse to make a follow-up call to the patient to make sure they kept their appointment, make a new one if necessary, and answer any questions that might come up about their care in the ED or the appropriate at-home after care. This may seem like a lot of hand holding, but that is what coordination of care often means, especially for the elderly; and this is just one piece of the coordination of care process.
The ED and the emergency physician and staff could also be responsible for coordinating nurse-advice services; patient transport to the ED; care during transport; pre-arrival registration; pre-arrival communication with care-givers or the SNF; with the patient’s PCP; coordination with all of the providers, services and staff involved in ED care; coordination with consultants; coordination with admitting physicians, and inpatient care nursing and other staff if the patient needs admission, coordination with other hospitals and EDs if repatriation to an in-network facility is indicated, and so on. In a busy, often overwhelmed, and underfunded ED, who has time to do all this? Imagine trying to do all this for every patient, not just for the one that has insurance and a so-called medical home. Certainly, it will take a team of staff to manage these complex processes, and who will pay to make that team and these systems available? Ask the government or the commercial insurer to pay extra for these services, and they will likely say that they thought they already were when they paid the facility and ED physician’s Evaluation and Management services claims.
Coordination of care in the ED is the right thing to do, but let’s not assume that ED physicians and staff can take this on as a value-added role that will forever guarantee the value proposition for emergency care without bringing to bear some additional resources, funding, and staff to incorporate the next iteration of care coordination into daily ED practice.
This post also appears on The Fickle Finger.