Case management intervention of high users of the emergency department of a Portuguese hospital: a before-after design analysis

Abstract

Background Emergency department (ED) High users (HU), defined as having more than ten visits to the ED per year, are a small group of patients that use a significant proportion of ED resources. The High Users Resolution Group (GRHU) identifies and provides care to HU to improve their health conditions and reduce the frequency of ED visits by delivering patient-centered case management integrated care. The main objective of this study was to measure the impact of the GRHU intervention in reducing ED visits, outpatient appointments, and hospitalizations. As secondary objectives, we aimed to compare the GRHU intervention costs against its potential savings or additional costs. Finally, we intend to study the impact of this intervention across different groups of patients. Methods We studied the changes triggered by the GRHU program in a retrospective, non-controlled before-after analysis of patients’ hospital utilization data on 6 and 12-month windows from the first appointment. Results A total of 238 ED HU were intervened. A sample of 152 and 88 patients was analyzed during the 6 and 12-month window, respectively. On the 12-month window, GRHU intervention was associated with a statistically significant reduction of 51% in ED visits and hospitalizations and a non-statistically significant increase in the total number of outpatient appointments. Overall costs were reduced by 43.56%. We estimated the intervention costs to be €79,935.34. The net cost saving was €104,305.25. The program’s Return on Investment (ROI) was estimated to be €2.3. Conclusion Patient-centered case management for ED HU seems to effectively reduce ED visits and hospitalizations, leading to better use of resources.

A mapping review of interventions to address patients who frequently seek care in the emergency department

“…There were no qualitative studies identified. Thirty-five (35) were from the US [ 14 , 16 , 26 – 58 ], five were from Canada [ 59 – 63 ], three were from each of the UK [ 64 – 66 ] and Australia [ 67 – 69 ], two were from each of Sweden [ 15 , 70 ], Taiwan [ 71 , 72 ], and Spain [ 73 , 74 ], and one was from each of Belgium [ 75 ], Denmark [ 76 ], Portugal [ 77 ], the Netherlands [ 18 ], Singapore [ 78 ], and Switzerland [ 79 ], Fig. 2 .…”

“…Study population size varied widely, ranging from seven participants to over 100,000. Fifteen studies had a study population of less than 100 [ 14 , 26 , 30 , 34 , 36 , 41 , 44 , 47 , 51 , 57 , 62 , 65 , 66 , 68 , 71 ], 24 had a study population of 100–500 [ 15 , 16 , 27 , 28 , 32 , 33 , 38 , 40 , 42 , 43 , 48 – 50 , 53 , 55 , 58 – 61 , 63 , 67 , 72 , 77 , 79 ], six had a study population of 500–1,000 [ 31 , 45 , 64 , 74 , 78 , 80 ], and 13 had a study population of more than 1,000 [ 18 , 29 , 36 , 37 , 39 , 46 , 52 , 54 , 56 , 69 , 70 , 75 , 76 ], Fig. 2 .…”

“…Additionally, 16 interventions were for “frequent users” as defined by the authors [ 14 – 16 , 28 , 39 , 41 , 42 , 47 , 49 , 55 , 64 , 65 , 68 , 70 , 77 , 79 ]. The definition of “frequent user” varied; some authors used patients with a specified number of visits in the last 12 [ 16 , 47 , 49 , 55 , 77 , 79 ] or six months [ 15 , 39 , 41 , 70 ], the number of visits during multiple periods of time [ 14 , 28 , 42 ], or the most frequent users over a period [ 65 , 68 ], such as the top 20 most frequent users in one quarter [ 68 ].…”

“…Several interventions were utilized in the literature, and many studies reported multi-faceted interventions, Table 1 . Overall, 36 studies reported on continuation of care interventions: 12 reported on care plans [ 15 , 26 , 28 , 30 , 38 , 41 , 42 , 45 , 49 , 68 , 70 , 75 ], nine reported on case management [ 14 , 15 , 44 , 47 , 55 , 63 , 64 , 72 , 79 ], eight reported on care coordination [ 16 , 39 , 48 , 50 , 58 , 65 , 69 , 77 ], six reported on follow-up phone calls [ 18 , 30 , 35 , 36 , 60 , 67 ], and one reported on a care transition intervention [ 51 ]. Seventeen interventions reported on additional services in the ED: four each reported on education [ 34 , 45 , 61 , 67 ] and geriatric assessment [ 72 , 75 , 76 , 78 ], two each reported on physical therapy services [ 27 , 29 ], specialist consultations [ 31 , 76 ], and medication review [ 27 , 74 ], and one each reported on early assessment and intervention [ 40 ], counselling [ 60 ], and telepsychiatry [ 46 ].…”

Unveiling the patterns: exploring social and clinical characteristics of frequent mental health visits to the emergency department—a comprehensive systematic review

“…Despite the importance of reducing ED waiting times and more hospital beds for mental health patients, we strongly advocate for more resources to be allocated to community mental health services with multiple benefits. On a community level, case-based management and a patient-centred approach can be tailored to specific patients’ needs, with a higher rate of patient satisfaction, better clinical outcomes, and reduced ED visits and admissions [ 82 , 83 ]. Nursing models such as the Buurtzorg [ 84 ] could be expanded to provide mental health support and social welfare services at a local level.…”