Rather than fighting to keep primary care concerns out of the ED, rural hospitals—and the patients they treat—stand to benefit from an emergency medicine-primary care partnership model that integrates the two domains, according to a paper recently published in the Annals of Internal Medicine.
The conventional wisdom—and why it doesn't work for rural providers
Both rural and urban providers are grappling with ways to lower ED utilization. But for rural providers, which typically have smaller operating margins and more ED patients who cannot afford care, high ED volumes mean higher rates of uncompensated care, which could present a business risk, Modern Healthcare reports.
Margaret Greenwood-Ericksen, lead author of the new paper and an emergency medicine physician at the University of Michigan, said, "I think in urban areas, efforts to reduce ED utilization are extremely important. But urban and rural areas are very different in many ways—so applying an urban model to a rural area doesn't really seem to be effective and doesn't take into consideration some of the barriers that are faced in rural areas."
For instance, in many rural areas, there may be significant physical distance between residents and the nearest provider, with EDs serving as the closest health care facility, Modern Healthcare reports. Simply put, Greenwood-Ericksen said, "The traditional urban model of health care has been ineffective at improving rural health."
A different approach
Instead of trying to make the traditional model work, rural providers should try an integrated emergency medicine-primary care model, the authors suggested. The authors wrote that their proposal "embraces the role that EDs play in providing primary care in rural areas and links patients' common point of access—the ED—to providers in primary care." The final model, according to HealthLeaders Media, imposes no physical walls between emergency and primary care.
As an example, the authors profiled Carolinas HealthCare System's rural Anson Community Hospital, which started working on an integrated emergency medicine-primary care model about five years ago. About one quarter of Anson's patient population is at or below the poverty level, according to Census Bureau data. Modern Healthcare reports that the area has been considered one of the state's unhealthiest for years.
In 2010, Carolinas realized that the hospital wasn't financially sustainable, Modern Healthcare reports. Michael Lutes, Carolinas HealthCare SVP and president of its Southeast Division, said, "We were really challenged as to how we were going to meet the community's needs."
Faced with this situation, Carolinas in 2012 replaced the hospital with a freestanding, 24-hour, 15-bed ED that is staffed with both emergency medicine andprimary care physicians who care for patients in need of non-emergency care. When patients arrive at the facility, navigators screen and direct them toward emergency or primary care.
According to Modern Healthcare, ED visits at Carolinas declined 7 percent in 2014, the first year that the facility operated under the new model. There have been moderate drops annually since then, Modern Healthcare reports. Further, according to Modern Healthcare, the model "has helped the facility become financially sustainable at a time when the number of rural hospitals closing their doors has increased."
According the researchers, the Carolinas case study indicates that similar ED-primary care models in other rural areas could help optimize ED care, improve public health, and "address rural populations' most pressing social and medical needs." The model may also help rural hospitals and health systems become more financially solvent, the researchers said.
A 'different model' of care
As Lutes put it, "What we wanted to do was build a model that was focused on improving the health status of Anson County." He explained, "We realized that in a lot of communities, the ED is a main access point to receiving care. ... I think our model is recognizing that and then using an intervention before they go into the ED."
Lutes said, "Taking those visits that were going into the ED—many of those we weren't being compensated for—and putting them in a lower-cost setting has obviously helped the hospital from a financial perspective." He added, "The fact that we found a different model to keep this hospital open, and at the same time improve health outcomes and access, I think has been pretty amazing" (Ross Johnson, Modern Healthcare, 8/11; Commins, HealthLeaders Media, 8/10; Greenwood-Ericksen et al., Annals of Emergency Medicine, 8/9).
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