SOCIAL EM & POPULATION HEALTH COMMITTEE
Transition to Outpatient Care After Emergency Department Discharge Brenda Arthur, MD and Jessica Pennington, BA
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ackground
A 2017 study by Chau et al7 investigates primary care access on a continuum related to ED care. This study offers updates on two prior patient-simulated studies performed by the Medicaid Access Study Group6 and Asplin et al.7 In 1994, the Medicaid Access Study Group found that patient-simulated callers who impersonated privately insured patients had easy outpatient access, while those impersonating patients with Medicaid were much more likely to be referred to the ED.7 Even recently, unsurprisingly, patients without established primary care (particularly indi-
Emergency medicine (EM) is the one field of medicine that creates physicians who are prepared to care for anyone, with any problem, on any day. The practice of EM includes caring for seemingly overlooked populations including, but not limited to: children, the elderly, patients who may not speak English as their primary language, survivors of trauma or abuse, individuals without stable housing, or patients without health Modest yield in successfully insurance or a primary care physician (PCP). In addition, EM is the scheduled post-ED follow-up only specialty where physicians are appointments does not say that not allowed to turn patients away, such programs are not worthwhile, regardless of age, disease process, as greater than 50% of our or ability to pay. By default, EM physicians provide patients with a patients who were scheduled safety net. At times, this may include for an outpatient visit made non-emergent medical care.
it to their appointment.”
Non-emergent care in the emergency department (ED) can disrupt continuity of care.1 Often, the ED is not the best environment for preventative care and management of chronic diseases.1,2 It also may be under-resourced to follow-up and address the continued challenges faced by the aforementioned overlooked populations.3 It is estimated that more than half of ED visits are avoidable, and more than a quarter of ED visits are recurrent.1 A 2022 paper published in the American Journal of Emergency Medicine proposes one explanation for return visits to the ED to be the perception by patients of poor access to outpatient care.1 Navigating our complex healthcare system alongside different social determinants of health hinders timely and necessary outpatient follow-up after a patient leaves the ED. Some barriers to outpatient follow-up are: 1) having patients schedule their own follow-up appointments,2 2) lack of insurance or transportation,4 3) perceived cost, 4) childcare, 5) work related reasons, 6) symptomatic improvement, 7) hospitalization, 8) patients unaware of their outpatient plan,5 9) mental illness, 10) substance use, 11) housing insecurity or 12) lack of access to a phone. In one study, patient race and ethnicity were not associated with the rate of outpatient follow-up.6
viduals with Medicaid) demonstrated a greater difficulty obtaining timely, outpatient follow-up after discharge from the ED.3,7,8,9 In contrast, different interventions have been shown to help improve patient access to outpatient medical care: 1) scheduling outpatient appointments prior to ED disposition,2 2) community based interventions such as telemedicine, expanded clinics, interrogations of emergency medical service pathways 3) care coordination from the emergency department (example, Skilled Nursing Facility (SNF) placement from the ED),10 4) case management telephone follow-up, 5) social work home visits, 6) diversion strategies that direct patients who do not require emergency department level care to appropriate non-ED settings,11 and 7) patient navigator programs.1 In general, patients are more likely to follow-up after an ED visit if they are not expected to schedule this follow-up themselves.2 While anecdotally ED utilization may be associated with outpatient follow-ups (or lack of), the 2017 article written by the Cooper University Hospital Division of Trauma suggests that improving outpatient follow-up does not prevent ED utilization by trauma patients, which is an interesting thing to consider.12 In a study on predictors of outpatient follow-up, the Journal of Asthma also suggests no association between outpatient follow-up and ED revisits. The authors do note that post-ED follow-up may >>
COMMON SENSE MAY/JUNE 2024
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