Creating Integrated Networks Of Emergency Care: From Vision To Value

Abstract

Emergency care is an essential component of the care delivery system in the United States, but it received little attention during the debates about health care reform. As a result, US emergency care remains outdated and fragmented. We provide an overview of efforts to regionalize emergency care in the United States, and we both identify challenges to change and recommend next steps in five domains: people, quality and processes, technology, finances, and jurisdictional politics. We offer a commonsense approach to increasing the value of emergency care delivery by developing regionalized integrated networks of emergency care that take advantage of emerging changes in the health system and are designed to meet time-sensitive patient needs. E mergency care is a crucial component of the health care delivery system in the United States, managing a disproportionately large portion of acute care and acute exacerbations of chronic conditions, and half of all hospital admissions.1,2 With health reform, the importance of emergency care seems destined to increase. The major focus of the Affordable Care Act is on expanding coverage to the uninsured and developing new models of care, with an emphasis on primary care and medical homes-settings that are both limited in their hours of availability and likely to refer 80 percent of their patients with acute and complex conditions to the emergency department (ED) for needed care. 2The existing emergency care system evolved in response to the public's need for access to acute care.3 With an increasing number of patients seeking such care, an aging population, an increased incidence of chronic diseases, physician and staff shortages, and a geographic maldistribution of health care resources, the US emergency care system is at an inflection point. The continuum of emergency care (including prehospital care, the ED, and the hospital-based subspecialists who support the emergency care capabilities of hospitals) must be transformed to provide greater public value-that is, highquality care at lower costs than those of current approaches to emergency care delivery.The ED was once thought of as a resource of last resort for the critically sick and dying. Today, however, it represents-for both patients and their providers-the first option for timely acute care. Only 7-10 percent of all ED visits are for nonurgent visits. 4 The vast majority of ED visits are emergent, urgent, or semi-urgent and require time-sensitive evaluation or intervention (Exhibit 1). The most common conditions among patients visiting the ED include chest pain, asthma, abdominal pain, headache, fever, upper respiratory tract infections, sprains, fractures, and wounds. The development of new models of care coordination, such as patient-centered medical homes and accountable care organizations; the increasing availability of electronic clinical information and enabling technologies, such as telemedicine and remote monitoring; and the shift toward incentives to increase value all provide opportunities to redesig...

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