Health policy/original research
An Intervention Connecting Low-Acuity Emergency Department Patients With Primary Care: Effect on Future Primary Care Linkage

Presented as an abstract at the Society for Academic Emergency Medicine annual meeting, Chicago, IL, May 2012.
https://doi.org/10.1016/j.annemergmed.2012.10.021Get rights and content

Study objective

Our objective is to determine whether a point-of-care intervention that navigates willing, low-acuity patients from the emergency department (ED) to a Primary Care Clinic will increase future primary care follow-up.

Methods

We conducted a quasi-experimental trial at an urban safety net hospital. Adults presenting to the ED for select low-acuity problems were eligible. Patients were excluded if arriving by emergency medical services, if febrile, or if the triage nurse believed they required ED care. We enrolled 965 patients. Navigators escorted a subset of willing participants to the Primary Care Clinic (in the same hospital complex), where they were assigned a personal physician, were given an overview of clinic services, and received same-day clinic care. The primary outcome was Primary Care Clinic follow-up within 1 year of the index ED visit among patients having no previous primary care provider.

Results

In the bivariate intention-to-treat analysis, 50.3% of intervention group patients versus 36.9% of control group patients with no previous primary care provider had at least 1 Primary Care Clinic follow-up visit in the year after the intervention. In the multivariable analysis, the absolute difference in having at least 1 Primary Care Clinic follow-up for the intervention group compared with the control group was 9.3% (95% confidence interval 2.2% to 16.3%). There was no significant difference in the number of future ED visits.

Conclusion

A point-of-care intervention offering low-acuity ED patients the opportunity to alternatively be treated at the hospital's Primary Care Clinic resulted in increased future primary care follow-up compared with standard ED referral practices.

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

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    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.

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