Health policy/original researchAn Intervention Connecting Low-Acuity Emergency Department Patients With Primary Care: Effect on Future Primary Care Linkage
Introduction
Nearly 1 in 5 adults aged 18 to 64 years in the United States lacks a usual source of health care.1 Emergency department (ED) patients may be even less likely to have a usual source of care, with up to one third reporting no usual source or identifying the ED as that source.2 Recognizing this as a high-priority problem, Healthy People 2020 identifies “persons with a usual primary care provider” as one of the leading health indicators to address in the next 10 years.3 Moreover, the success of new care delivery models such as patient-centered medical homes hinges on patients having a usual source of care.
Having a usual source of primary care has well-established health benefits. People with a usual source of care are more likely to receive preventive services,4 including blood pressure screening,5, 6 vaccinations,7 mammograms,5, 6, 7 Papanicolaou smears,5, 6 colorectal cancer screening,8 and prenatal care.9 It is commonly accepted that regular attention to chronic illness may prevent more severe, costly problems. Previous studies support this notion; for example, patients without a primary care provider have higher odds of presenting to the ED for severe, uncontrolled hypertension,10 and ED patients without a usual source of care have worse diabetes control, even after adjusting for potentially confounding factors.11
Despite the health benefits of having a usual source of primary care, the best way to establish such care is unknown and efforts to improve this process have proven difficult to realize. Given its position as the point of entry into the health care system for many underserved patients, the ED may be an ideal place for interventions to improve access to primary care. Previous ED-based interventions have attempted to encourage primary care follow-up, with various levels of success.12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 Most interventions occurred after the ED visit through enhanced referral systems or assistance in making appointments. There may be an opportunity to intervene earlier, even before the ED visit is completed, to connect a select group of low-acuity patients with primary care. Nationwide, 8% of ED visits are classified as nonurgent, defined as requiring care within 2 to 24 hours,23 and this number may be higher in certain settings such as safety net hospitals.24 Same-day, closely observed care in a Primary Care Clinic, which more proactively connects ED patients with a usual source of primary care, could be a safe option for a subset of these ED visitors.
We aimed to determine whether a point-of-care intervention that navigated willing, low-acuity patients from the ED to a Primary Care Clinic would increase future primary care follow-up. We hypothesized that such an intervention could create successful primary care follow-up among patients with no previous usual source of care.
Section snippets
Study Design and Setting
We conducted a quasi-experimental trial at an urban public safety net hospital. The study hospital's Primary Care Clinic is located in the same building complex as the ED. The outpatient clinics have more than 500,000 visits yearly and another 100,000 patients are treated yearly in the ED. The adult ED consists of 2 treatment areas: the main adult emergency service and the urgent care area.
The study was approved by the institutional review boards of the study hospital and its affiliated
Results
Of 1,404 eligible patients, 439 refused and 965 were enrolled (Figure 1). Overall, 191 patients were assigned to the ED Urgent Care group and 662 to the Primary Care Clinic group. Ninety-nine Primary Care Clinic group patients refused the intervention and remained in the ED Urgent Care. Reasons for refusal included needing medication refills (at our hospital's pharmacy, prescriptions are free only if originating from the ED), believing that care would be quicker in the ED, and fearing extra
Limitations
This study was conducted at one safety net hospital and the findings may not be generalizable to other hospitals. However, we are encouraged that our intervention resulted in increased primary care follow-up, even considering the challenges inherent in working with our high-risk patient population. Additionally, 31% of eligible patients refused study enrollment, and thus our findings may not be generalizable to all users of the ED.
We could track health care use only at our hospital, and it is
Discussion
An intervention navigating low-acuity ED patients to the Primary Care Clinic resulted in significant improvement in future primary care follow-up compared with usual ED referral practices. For Primary Care Clinic group patients, this meant at least 2 visits to the same Primary Care Clinic within 1 year: the index study visit and at least 1 follow-up visit. In contrast, most previous ED-based interventions used the outcome of a single follow-up visit after the ED visit. We believe the initial
References (55)
- et al.
Barriers to timely prenatal care among women with insurance: the importance of prepregnancy factors
Obstet Gynecol
(2000) - et al.
Randomized controlled trial of emergency department interventions to improve primary care follow-up for patients with acute asthma
Chest
(2006) - et al.
A randomized, controlled trial of a simple emergency department intervention to improve the rate of primary care follow-up for patients with acute asthma exacerbations
Ann Emerg Med
(2001) - et al.
Achieving graphical excellence: suggestions and methods for creating high-quality visual displays of experimental data
Ann Emerg Med
(2001) - et al.
Does lack of a usual source of care or health insurance increase the likelihood of an emergency department visit? results of a national population-based study
Ann Emerg Med
(2005) - et al.
Impact of an Internet-based emergency department appointment system to access primary care at safety net community clinics
Ann Emerg Med
(2009) - et al.
Factors associated with failure to follow-up at a medical clinic after an ED visit
Am J Emerg Med
(2012) The ED is an efficient place to treat ED patients
Am J Emerg Med
(2004)- et al.
If you want to fix crowding, start by fixing your hospital
Ann Emerg Med
(2007) - et al.
Time series analysis of variables associated with daily mean emergency department length of stay
Ann Emerg Med
(2007)
Requiem for “non-urgent” patients in the emergency department
J Emerg Med
Nonurgent use of the emergency department—appropriate or not
Ann Emerg Med
ED patients: how nonurgent are they? systematic review of the emergency medicine literature
Am J Emerg Med
Using medical screening examinations to reduce emergency department overcrowding
J Emerg Nurs
Refusing care to patients who present to an emergency department
Ann Emerg Med
Triage of patients out of the emergency department—3-year experience
Am J Emerg Med
Patients' perspective on choosing the emergency department for nonurgent medical care: a qualitative study exploring one reason for overcrowding
J Emerg Nurs
The hospital emergency department as a social welfare institution
Ann Emerg Med
Summary health statistics for US adults: National Health Interview Survey, 2009
Vital Health Stat 10
Ambulatory visits to hospital emergency departmentsPatterns and reasons for use. 24 Hours in the ED Study Group
JAMA
Healthy People 2020
Receipt of preventive care among adults: insurance status and usual source of care
Am J Public Health
Does having regular care by a family physician improve preventive care?
Can Fam Physician
Primary care and receipt of preventive services
J Gen Intern Med
Preventive care
J Gen Intern Med
Progress in cancer screening over a decade: results of cancer screening from the 1987, 1992, and 1998 National Health Interview Surveys
J Natl Cancer Inst
Predisposing factors for severe, uncontrolled hypertension in an inner-city minority population
N Engl J Med
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2022, Health PolicyCitation Excerpt :Additionally, ED crowding is associated with worse quality of care and worse perception of care, the studied intervention might mitigate this effect [45]. There may also be a long-term effect, as patients who were previously introduced to the GPC will visit a GP more readily in the future [46]. On average, the intervention was associated with a lower invoice paid for by the patient (€26 vs. €28) and a higher invoice for the insurance (€97 vs. €91).
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2022, International Emergency NursingCitation Excerpt :Therefore, this intervention also educates eligible patients about the GPC, hoping that in the future, when they have a medical problem with a similar degree of urgency, they will prefer the GPC over the ED. This is a position that is supported by Philips et al. [42] and Carret et al. [12] and has been shown to be successful in Doran et al. [43]. However, for the extra time necessary for the intervention to be justifiable it may not exceed the projected care time of the patient.
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Discharge to medical home: A new care delivery model to treat non-urgent cases in a rural emergency department
2019, HealthcareCitation Excerpt :Other studies have found that directing ambulatory patients to a hospital-integrated general practice uses less time, fewer diagnostic resources than the ED, and that hospital based screening reduces the burden of inappropriate ED use.9,10 Hospital-based screening interventions have shown higher rates of primary care follow up for ED patients who do not have a regular source of care.11 However, limited research describes the efficacy or implementation of moving patients from the ED to a primary care clinic, with no interventions aimed at a rural population in the United States.
The Effectiveness of Emergency Department Visit Reduction Programs: A Systematic Review
2016, Annals of Emergency MedicineCitation Excerpt :A secondary comparison group included ED patients who met eligibility criteria but who had a primary care provider outside the study hospital. The study found no reductions in ED visits at 12-month follow-up comparing intervention to usual care groups (adjusted mean difference –0.23; 95% confidence interval –0.61 to 0.16) and did not assess hospitalization rates or mortality.46 Five studies examined the effect that imposing ED copayments at the visit had on ED use.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. The Primary Care Access Project was supported by a grant from The Commonwealth Fund. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and the preparation, review, or approval of the article.
Please see page 313 for the Editor's Capsule Summary of this article.
Author contributions: ACC, RAH, ABW, MT, MHA, and LRG conceived of the study and designed the trial. RAH, MHA, and LRG obtained funding. RAH and LRG provided study supervision. KMD, ACC, and CKN participated in data acquisition and management. KMD, ACC, NDW, and SPW analyzed and interpreted the data. SPW performed statistical analysis. KMD and SPW drafted the article, and all authors provided critical revision of it. SPW had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. SPW takes responsibility for the paper as a whole.
Supervising editor: Michael J. Schull, MD, MSc
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An incorrect version of Figure 2 was included in this article while online between December 19, 2012, and January 8, 2013.
Publication date: Available online December 19, 2012.