Contact email

klaskowski@bwh.harvard.edu

Overview

The emergency department (ED) at Brigham and Women’s Hospital implemented a community health worker (CHW)-based program to improve care coordination for frequent ED users and decrease healthcare utilization and costs. 

Department

Department of Medicine

Division

Division of General Internal Medicine

Status/Stage of Development

Planning

Funding Sources

This project was funded by the following sources:

Brigham and Women’s Provider Organization Care Redesign Incubator Startup Program
American Board of Medical Specialties Visiting Scholar Award

Practice Setting

Academic Medical Center

National/Policy Context

• Frequent emergency department (ED) users are known to have disproportionately higher rates of chronic illness, increased healthcare utilization, and lower socioeconomic status, regardless of insurance status. For these patients, their primary contact with the healthcare system is in the ED. 
• Reducing unnecessary ED visits from frequent ED users is becoming increasingly important as alternative payment models, focused on value-based payment, become more common.
• Methods to reduce ED visits that have been studied previously include: engagement of ED providers in care coordination, intensive case management, information sharing, individualized disease management, and patient education.
• Unlike case managers or social workers, community health workers (CHWs) are laypersons in the community who are trained as public health workers and thus have a deeper understanding of the cultural and social factors within the community. CHW-based programs utilize these trained community members to work with frequent ED users. 
• Observational studies on the use of CHW-based programs have shown promising findings in reducing ED visits and decreasing healthcare utilization in patients with chronic illness and recent hospitalizations. However, randomized controlled trials are lacking, as well as studies on the cost-efficiency of these programs.

Local/Organizational Context

The authors sought to perform a randomized control trial on a pilot CHW program at Brigham and Women’s Hospital, with the goal of increasing care coordination in the ED and reducing ED visits, healthcare utilization, and healthcare costs associated with frequent ED users.

Patient Population Served and Payor Information

• This intervention included patients at Brigham and Women’s Hospital with the most ED visits in both the 30-day period and the 12-month period preceding the beginning of the program. This selection criteria allowed for selection of chronic frequent ED users while excluding users who had a single health event leading to multiple ED visits. 
• The 72 patients with the most ED visits were chosen and randomly split, with half in the intervention group and half in the control group.
• Among the 72 patients in the study, 91% in the intervention group and 83% in the control group had Medicare or Medicaid coverage.

Project Research + Planning

• The innovators found that there were promising results in observational studies on the use of CHW programs to reduce ED utilization in frequent ED users, but no randomized controlled trials studying this intervention had yet been performed. 
• The intervention study was approved by the authors’ institutional review board.

Tools or Products Developed

• Acute care plan: For each patient in the intervention group, the ED team worked with the patient’s consistent health care providers (PCPs, specialists, and social workers) to form an acute care plan with the goal of improving the efficiency and coordination of the patient’s ED care. This plan was uploaded to the patient’s EHR record and flagged to be visible during the patient’s ED visits.

Training

• A community health worker (CHW) was hired and trained for this intervention.
  •  The CHW’s role included performing chart reviews, performing standardized intake assessments for all patients in the intervention group.
  • In these assessments done through phone calls and home visits, the CHWs addressed social and care coordination needs such as establishing care, transportation, accessing food banks, and engaging with other community-based resources.

Tech Involved

• Electronic medical record

Team Members Involved

• Community Health Worker
• Physicians
• RNs

Workflow Steps

• ED physicians and physician assistants performed chart reviews for all 36 patients in the intervention group, focusing on the medical and social drivers for the patient’s frequent ED visits.
• The ED team worked with each patient’s consistent providers (PCPs, specialists, and social workers) to form an acute care plan for the patient’s ED care. The goal of this plan was to improve the efficiency and coordination of the patient’s ED care. The plan was uploaded to the patient’s EHR and flagged to be visible during the patient’s ED visits. 
• The CHW focused on addressing issues with care coordination and social needs for each patient.
  •  The CHW performed chart reviews for all patients in the intervention group and performed standardized intake assessments via phone call to identify each patient’s unmet needs. 
  • The CHW addressed these needs over the phone and/or during home visits, providing assistance with establishing care, transportation, and access to food banks and other community-based resources. 
  • The ED team paged the CHW if patients in the intervention group arrived at the ED during working hours, allowing each ED visit to act as a point of contact for improving access to follow-up care and community-based resources.
• Each week, a team composed of the CHW, a physician, and a nurse care coordinator met to distribute tasks and discuss the needs and progress of all patients.

Budget

• $50K to $75K

Outcomes

• The authors retrospectively analyzed outcomes from the first seven months of the intervention, including the effect of the intervention on ED visits, subsequent hospitalizations, and cost of care per patient. 
• Patients in the intervention group had 35% fewer ED visits (not statistically significant, p = 0.10) and 31% fewer subsequent hospitalizations (not statistically significant, p = 0.20). 
• The average cost of ED care episode per patient was 15% lower in patients in the intervention group (reduction of $2,247/patient). The average cost of inpatient care episode per patient was 8% lower in patients in the intervention group (reduction of $802/patient). 
• The intervention reduced annualized costs to the hospital by a total of $117,997.

Future Outcomes

• Future studies should evaluate health outcomes for patients and more long-term outcomes for healthcare utilization and cost. 

Benefits

• The intervention demonstrated a trend toward reduced ED visits, inpatient hospitalizations, and cost of care in frequent ED users.
  • This intervention utilized CHWs, who are members of the community and thought to provide more culturally competent care. 
  • CHWs provided a wide range of social and care coordination services to patients, including assistance with establishing care, transportation, and access to food banks and other community-based resources that were tailored to each patient’s specific needs. 
• This intervention demonstrates the potential for an interdisciplinary ED-based, CHW-based model for improving care coordination, reducing unnecessary healthcare utilization, and reducing healthcare costs for both patients and hospitals. 
• This intervention required an annualized cost of $55,115 to implement but reduced annualized costs to the hospital by a total of $117,997, demonstrating a positive return on investment. 

Intervention-Specific Challenges

• The study was likely underpowered because of its small sample size (n = 72), which may have prevented the results from being statistically significant. 
• Only patients’ visits to Brigham and Women’s Hospital were included in the analysis; therefore, it is not known whether this intervention had any effect on outside hospital visits. 
• The authors note that seasonality (the study took place during the winter) may have also affected the results by impacting the overall level of ED and hospital utilization. 
• One of the biggest challenges in implementing quality improvement interventions such as this one is the up-front cost, including the cost of hiring and training new staff. 
  • However, this intervention demonstrated a positive return on investment, which did not include the likely additional revenue of having fewer frequent ED user visits and thus increased capacity for other patients.

Glossary

• Community health worker (CHW): CHWs are laypersons in the community who are trained as public health workers and thus have a deeper understanding of the cultural and social factors within the community.

Personnel Challenges

• Lin MP, Blanchfield BB, Kakoza RM, Vaidya V, Price C, Goldner JS, Higgins M, Lessenich E, Laskowski K, Schuur JD. ED-based care coordination reduces costs for frequent ED users. Am J Manag Care. 2017 Dec;23(12):762-766. PubMed PMID: 29261242.
• Baker DW, Stevens CD, Brook RH. Regular source of ambulatory care and medical care utilization by patients presenting to a public hospital emergency department. JAMA. 1994 Jun 22-29;271(24):1909-12. PubMed PMID: 8201734.
• Community health workers. American Public Health Association website. apha.org/apha-communities/member-sections/community-health-workers. Accessed June 7, 2019.
• Enard KR, Ganelin DM. Reducing preventable emergency department utilization and costs by using community health workers as patient navigators. J Healthc Manag. 2013 Nov-Dec;58(6):412-27; discussion 428. PubMed PMID: 24400457; PubMed Central PMCID: PMC4142498.
• Gary TL, Batts-Turner M, Yeh HC, Hill-Briggs F, Bone LR, Wang NY, Levine DM, Powe NR, Saudek CD, Hill MN, McGuire M, Brancati FL. The effects of a nurse case  manager and a community health worker team on diabetic control, emergency department visits, and hospitalizations among urban African Americans with type 2 diabetes mellitus: a randomized controlled trial. Arch Intern Med. 2009 Oct 26;169(19):1788-94. doi: 10.1001/archinternmed.2009.338. PubMed PMID: 19858437; PubMed Central PMCID: PMC5675128.
• Hansagi H, Olsson M, Sjöberg S, Tomson Y, Göransson S. Frequent use of the hospital emergency department is indicative of high use of other health care services. Ann Emerg Med. 2001 Jun;37(6):561-7. PubMed PMID: 11385324.
• Hunt KA, Weber EJ, Showstack JA, Colby DC, Callaham ML. Characteristics of frequent users of emergency departments. Ann Emerg Med. 2006 Jul;48(1):1-8. Epub 2006 Mar 30. PubMed PMID: 16781914.
• Soril LJ, Leggett LE, Lorenzetti DL, Noseworthy TW, Clement FM. Reducing frequent visits to the emergency department: a systematic review of interventions. PLoS One. 2015 Apr 13;10(4):e0123660. doi: 10.1371/journal.pone.0123660. eCollection 2015. Review. PubMed PMID: 25874866; PubMed Central PMCID: PMC4395429.
• Sun BC, Burstin HR, Brennan TA. Predictors and outcomes of frequent emergency department users. Acad Emerg Med. 2003 Apr;10(4):320-8. PubMed PMID: 12670845.