Towards Healing: Emergency Department Utilization and the Recuperative Care Center
Santa Cruz County Emergency Department Data Trends
At September HIP Council representatives from Dominican Hospital and Central California Alliance for Health (Alliance) shared emergency department (ED) data trends from the perspective of their organizations. Greg Whitley, MD, ED Medical Director of Dominican Hospital, presented information from Dominican’s emergency department, a facility with 22 rooms and 24 beds. At Dominican Hospital, ED volume is on the rise, increasing from 40,000 visits in 2013 to 52,000 visits in 2016—a number that is expected to be met or exceeded in 2017. The turnaround time to discharge (the time from arriving at the ED to leaving the ED) has gone down since 2013, from 155 minutes to 140 minutes, and the time to see a provider (the time from arriving at the ED to seeing a physician) has remained steadily below the median of 30 minutes, at 10-12 minutes. The turnaround time to admit a patient, however, has grown since 2013 and is now well above the median of 300 minutes, at 349 minutes. Patient satisfaction—measured by survey results that indicate a patient would recommend the Dominican Hospital ED without hesitation—has gone down so far in 2017 compared to 2016, but has improved overall since 2013 to over 84%.
The ED has been able to make these high impact improvements by implementing many different strategies. Dominican staff have created standards of necessary tests to be returned to admit a patient to the hospital. This process streamlines patients from the ED to inpatient care and alleviates ED bed space for incoming patients. Improvements in efficiency have also been achieved by matching staff capacity to predicted demand, and triaging patients by complexity by separating patients into acuity streams based on need for certain resources. Also in the name of efficiency, the ED is using scribes to take down patient information and evaluations, allowing providers to spend more time focused on patients. The implementation of case management services in the ED has also made a significant impact by connecting patients to social and medical services like Janus of Santa Cruz or skilled nursing facilities, to help prevent future avoidable visits. Dominican also hosts the High Utilizer Group (HUG) monthly meetings to identify and discuss high frequency patients of the ED in collaboration with community organizations coordinating care outside of the hospital for these individuals’ mental, behavioral health, substance use disorder treatment and housing needs.
Dale Bishop, MD, Chief Medical Officer of the Alliance, present ED data for Alliance patients in Santa Cruz County. ED visits for adults were reduced by 25% since the full implementation of the Affordable Care Act in 2014. The most popular diagnosis among patients of all ages were abdominal and pelvic pain, acute upper respiratory infections, and pain in throat and chest. The most popular diagnosis in children was upper respiratory infection, which may not warrant an ED visit. The Alliance has several ongoing programs and efforts to help reduce overall ED visits. One program is Care-Based Incentives, which rewards providers who keep extended hours or become a Patient-Centered Medical Home. By incentivizing preventative care in the primary care setting, the Alliance seeks to reduce avoidable ED visits. The Alliance also provides a Nurse Advice Line, a resource Alliance members can use to receive provider assistance to determine if a situation warrants an ED visit. If a patient’s condition is not an emergency, the nurse will facilitate scheduling a provider visit, usually within 48 hours. The Alliance also offers case management services to members in need of more comprehensive care coordination. Finally, in preparation for Health Homes implementation, the Alliance has recently released a grant opportunity for qualifying health centers to hire staff to provide case management for their Medi-Cal patients and create data reporting infrastructure within the clinic setting.
Recuperative Care Center (RCC)
The RCC offers a facility for homeless individuals to recover after their ED visits or other medical procedures and services to prevent future avoidable ED visits. Tom Stagg, Director of Programs at Homeless Services Center, Joey Crottogini, Health Center Manager for Homeless Persons Health Project, and Paul Gendreau, RN, Public Health Nurse, presented about the twelve-bed transitional medical shelter, located on the Homeless Services Center campus and medically staffed by Homeless Persons Health Project. RCC receives referrals from area hospitals and other providers of adult homeless patients discharged from inpatient stays who need a place to stay during recovery. At the RCC, patients receive medical care, integrated behavioral health care, and integrated social services, including access to 24-hour bed rest, showers, nutritious meals, safe storage of medications and medical supplies, pharmacy services and medication management support, transportation to medical appointments, establishment of a medical home, self-care management of chronic conditions, eligibility assistance for health insurance, disability and other benefits, and housing case management.
Many of the patients admitted to RCC struggle with substance use disorders in addition to their medical ailments, creating further barriers to recovery. RCC uses a harm reduction model to address patients’ substance use disorders: use and possession on campus is prohibited, as is paraphernalia. RCC staff does not police patient activities outside of the Homeless Service Center campus, but will intervene if a patient’s behavior on campus interferes with their treatment or that of other patients. This model makes the RCC more accessible to people with substance use disorders, who would otherwise be discouraged from seeking care. In their final remarks, the presenters suggested that having more sober living environments available to the patients after their discharge from the RCC would have a significant positive impact on their recovery and diminish the likelihood of landing back in the ED or in-patient setting.