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February 15, 2019

5 ways to keep high-cost patients out of the ED, according to the patients themselves

Daily Briefing

    High-need patients make up just 5% of U.S. patients but account for almost half of health care spending—yet researchers know little about what these patients want and expect from providers.

    To learn more, a group of researchers tried a simple solution: asking the patients directly.

    Bridging the information gap

    Researchers Weill Cornell Medicine and University of Florida led focus group discussions with 21 high-need, high-cost patients and three primary caregivers at health care systems in New York City and Gainesville, Florida.

    To qualify for the study, patients had to have at least one chronic medical condition, as well as either two or more inpatient admissions or three or more ED visits in the six months before the study. On average, the patients had 16 ED visits, six primary care visits, and five hospitalizations in the last 12 months, and the most commonly reported medical conditions included arthritis, diabetes, asthma, and heart disease.

    What patients said

    The patients named five care delivery solutions they believed could improve their care and reduce the number of unnecessary ED and inpatient visits:

    • Care management;
    • At-home nursing services and physical therapy;
    • Home delivery of prescription medications;
    • Telemedicine; and
    • More after-hours clinics.

    Patients said they liked receiving help from care managers, whom patients view as "trustworthy partners in their day-to-day health care," the researchers write. Many patients said having a care manager to talk to when they weren't feeling well relieved some anxiety about their conditions and also prevented them from going to the ED unnecessarily. "When I talk to her it calms me down," one patient said about their care manager. "She [told me to] take some...over-the-counter medication that helps me [so] that I don't have to run to the [ED]."

    Patients also said they appreciate home-based services, especially when they have mobility restrictions or were recently discharged after an operation. One patient said having a nurse and physical therapist visit their home after a hip replacement allowed them to recover at home, which likely reduced their hospital visits.

    Medication delivery also helped patients who had mobility restrictions and transportation challenges. One patient suggested that providers give patients a "90-day supply" of their medications instead of a 30-day supply.  

    Patients named telemedicine as a possible alternative to regular doctors' appointments. The patients "felt that communicating with a medical provider who was personable and familiar with their symptoms could reduce the anxiety of time-sensitive, unanswered questions that often result in an ED visit," the researchers write.

    However, some patients said telemedicine might not be the best solution for some conditions, such as  cardiovascular disease, and explained they'd rather receive in-person care in case something were to go wrong.

    Lastly, patients who were unable to seek care during normal business hours said that after-hours clinics could reduce trips to the ED. But patients with transportation challenges pointed out that any after-hours locations would need to be conveniently located.

    Alternative solutions should be more widespread, researchers argue

    According to the researchers, almost "all of these solutions are being piloted in various settings" but should be "more widespread and better publicized" for patients who might not be aware of them. Further, the health care systems should also "consider directing more resources to some of these existing solutions."

    In summary, as health care decision makers look to improve care quality and reduce costs, the researchers write, "It is imperative that we leverage the expertise of a group of stakeholders who know a tremendous amount about bending the health care cost curve: the high-need, high-cost patients themselves" (Tanmoy Das et al., NEJM Catalyst, 2/5).

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