Date of Award

January 2023

Document Type

Open Access Thesis

Degree Name

Doctor of Nursing Practice (DNP)

Department

Yale University School of Nursing

First Advisor

Mary A. Camilleri

Abstract

Purpose: This DNP project developed an ED-initiated Advanced ED Care Management Program (AECM) to reduce the frequency of and costs associated with ED overutilizers with four or more ED visits in a rolling calendar year, excluding those with private insurance in an assisted living or skilled nursing facility, or who have a primary behavioral health diagnosis or chief complaint. Background: Overutilizers of the emergency department (ED) consume a significant proportion of healthcare resources and makeup approximately 21-28% of all ED visits in the United States. Adult ED overutilizers' care routinely fractures as a downstream effect due to the lack of consistent primary and specialized follow-up care available to the patient. The root cause of ED overutilization is multifactorial; however, the utilization of resources is significant when considering the financial and social costs to the patient, community, and organization. Methods: This process improvement project developed and implemented an AECM program with a multidisciplinary task force utilizing an adapted AHRQ Reengineered Discharge Toolkit and patient navigator to establish system linkages for advanced ED care management post-discharge. The program was implemented in three Emergency Departments within an extensive healthcare system with a combined annual volume of 130,000 visits. Program effectiveness was evaluated using descriptive and bivariate statistics. Results: A total of 30 patients were identified and originally enrolled in the ED Advanced Care Management Program. Three patients did not follow thru with the program, and one was classified as an unexpected death. 26 patients completed the program in its entirety. The program ran from October 2022 to January 2023. A chi-square test of independence was performed to examine a link between the AECM program and the reduction of the number of ED Overutilizer visits compared to historical data collection in 2018 and 2019. There was a statistically significant relationship between the two variables. Descriptively there was a 0.5% mean overall ED Overutilizer reduction, and the mean ED Visit Count for enrolled patients reduced from 3.12 (SD=2.15)/quarter to 2.27 (SD=1.6)/quarter. The project yielded an estimated direct and indirect financial impact of +$156,950/quarter, related to avoided ED visit costs and additional downstream revenue capture through in-network referrals. Conclusion: This pilot program demonstrated that an ED-initiated Advanced Care Management approach with post-ED discharge telehealth follow-up effectively connects vulnerable patients to the appropriate level of care using the system and community-based resources to reduce ED recidivism. This collaborative care approach can manage chronic, long-term, or debilitating diseases and short-term recurring medical concerns or needs. Implications for scale include extending the model to all large hospital EDs across the healthcare system and in post-acute care discharge to address ED overutilization and improve health outcomes.

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