Safety Net Hospital Emergency Departments: Developing Safety Valves for Non-Urgent Care

Safety Net Hospital Emergency Departments: Developing Safety Valves for Non-Urgent Care

Issue Brief No. 120 -- May 2008 -- Laurie E. Felland, Robert E. Hurley, Nicole M. Kemper

Hospital emergency departments (EDs) are treating growing numbers of patients, including those with non-urgent needs that could be addressed in alternative, more cost-effective settings, such as clinics or physician offices. According to findings from the Center for Studying Health System Change's 2007 site visits to 12 nationally representative metropolitan communities, many emergency departments at safety net hospitals -- the public and not-for-profit hospitals that serve large proportions of low-income, uninsured, and Medicaid patients -- are working to address patients' non-urgent needs more efficiently. Safety net EDs are trying to redirect non-urgent patients to their hospitals' outpatient clinics or to community health centers and clinics, with mixed results. Expanding primary, specialty, and dental care in community settings, along with encouraging patients to use these providers, could reduce ED use for non-urgent care while improving access, enhancing quality, and containing costs.

Busy Emergency Departments See More Non-Urgent Patients

Emergency department visits are on the rise, especially for patients with non-urgent conditions. Such conditions could include cold and flu symptoms, minor cuts and sprains, rashes, dental problems, and prescription refills. The National Hospital Ambulatory Medical Care Survey (NHAMCS) found that total ED visits classified as non-urgent -- meaning the patient should be treated within two to 24 hours -- increased from approximately 10 percent of ED visits in 1997 to 14 percent of visits in 2005, with uninsured patients experiencing a slightly higher increase. People with private insurance accounted for the largest share of the overall increase in ED visits. However, low-income uninsured and Medicaid patients rely on emergency departments more heavily than people with Medicare or private coverage.

Low-income, uninsured, and underinsured patients frequently turn to EDs for care because they lack timely access to outpatient care in other settings. The growing reluctance of physicians and dentists to serve Medicaid and uninsured patients, combined with shortages of primary care physicians and certain specialists like psychiatrists in some communities, makes obtaining clinic or physician appointments increasingly difficult, according to findings from HSC's 2007 site visits.

Community health centers have broadened access to care in underserved areas but still struggle to meet growing demand for primary care. Many safety net hospitals have primary and specialty care clinics that serve as key sources of care for low-income people, yet these too face capacity constraints, and waits for appointments can stretch to several months. As one Boston ED director noted, "We see people coming back to the ED two to three times because they can't get an appointment with a specialist."

Emergency departments serve as convenient sources of care because they operate 24 hours a day, cannot turn patients away without screening them, and many are located in urban areas accessible by public transportation. At an ED in Lansing, a representative of a Medicaid health plan asked Medicaid enrollees why they chose the ED over their primary care provider -- key reasons included difficulty obtaining appointments with network providers and lack of affordable transportation to other providers. Some ED directors and other observers also suggested that safety net EDs have accommodated low-income patients over time and become the preferred provider of choice for some.

However, there are concerns about using the ED for non-urgent care. EDs are frequently crowded with patients waiting for hospital admission. People with non-urgent needs may add to wait times for all patients, including those with emergent conditions, which can negatively affect patient outcomes. In addition, ED capacity is expensive given the range of standby services and equipment EDs must maintain, and studies have found that providing non-urgent care may cost more in emergency departments than in other settings. Interviews with ED directors at the main safety net hospitals in the 12 HSC communities highlighted ways EDs are trying to better manage the volume of non-urgent care they deliver and improve access for people in the communities they serve.

Redirecting Non-Urgent Patients

Some safety net hospitals are expanding their emergency departments to handle increased overall patient volumes and attract more well-insured patients, but this is an expensive way to address non-urgent care needs. While some hospitals are trying to treat non-urgent patients more efficiently -- for example, using a "fast-track" approach where mid-level practitioners provide care in a setting separate from the ED -- such strategies may actually attract even more non-urgent patients.

Rather than trying to serve more non-urgent patients, many safety net EDs are working to help patients establish "medical homes" that provide preventive and primary care for both episodic medical needs and chronic conditions, with coordination of follow-up visits and tests. Such providers -- including hospital outpatient clinics, community health centers, and individual primary care practitioners -- may deliver less costly care, decrease reliance on the ED for non-urgent conditions, and reduce the likelihood of untreated non-urgent problems escalating into more severe ones.

Some safety net hospitals are adding primary care capacity and collaborating more closely with hospital specialty clinics to treat more patients needing follow-up care. For example, an Orange County hospital recently built an internal medicine clinic to serve uninsured patients, a Boston hospital added more family medicine clinics, and an Indianapolis hospital opened a clinic for Spanish-speaking patients. In Miami -- where a quarter of the population is uninsured -- a safety net hospital restructured its clinics to make them more efficient and enable more patients to be seen, transforming a visit from being an "all-day experience" to average waits of 75-90 minutes. That hospital also added school-based clinics and mobile vans to deliver care in the community without the overhead costs of full-scale clinic facilities.

To encourage use of outpatient clinics and community health centers, some EDs -- after screening patients as required by the federal Emergency Medical Treatment and Labor Act (EMTALA) -- assist patients with non-urgent conditions in identifying other providers and scheduling appointments. A Miami ED added a nurse practitioner to determine which patients could be treated in a clinic setting and administrative staff to schedule appointments with primary care or dental clinics on the same day or within three days. Over 18 months, ED staff referred an average of 50 patients a day to clinics -- nearly double what they initially expected and approximately 15 percent of total ED volume.

Another approach used in some communities is to dedicate ED staff to work with patients before they arrive -- in some cases targeting frequent visitors -- to direct them to primary care settings for non-urgent needs. A Greenville ED added a nurse patient advocate to help patients establish a medical home in the community by linking them to private physicians, free clinics, and community health centers. Similarly, a Seattle ED identifies patients -- many with mental health conditions -- with 14 or more visits per year and creates a patient care plan, referring patients who lack a medical home to the hospital's clinics or community health centers.

Community Clinic Linkages

Involvement of community health centers and other primary care clinics is essential to safety net hospital efforts to control the amount of non-urgent care provided in emergency departments, particularly for hospitals without their own clinics. The national associations representing community health centers and Medicaid health plans support efforts to provide a continuum of care through a medical home to reduce the need for patients to turn to EDs for non-urgent care. Health center directors are largely supportive of taking on more patients diverted from the ED, and some have adopted same-day scheduling or walk-in appointments to enable patients to be treated more quickly.

Recognizing that community clinics can relieve pressure on EDs, several safety net hospitals -- in communities such as Seattle, Phoenix, and Miami -- are collaborating with health centers. For example, one hospital was in discussions with an area health center about helping the center extend hours to evenings and weekends to see more patients diverted from the ED. However, without sufficient support for community health centers in the form of direct funding or additional revenue from treating more insured patients, absorbing more patients would create a financial strain. One health center director noted a previous arrangement with a for-profit hospital where the ED sent the center uninsured patients but few insured patients.

In a number of communities, health information technology enables scheduling appointments with other providers and sharing a patient's clinical information between EDs and other providers. In Boston, Cleveland, Indianapolis, and Lansing, some clinics and physician offices can connect to the electronic medical record system in EDs to schedule appointments and better track a patient's condition and previous tests and treatments, although many systems provide read-only access and cannot transfer information back and forth. In Greenville, safety net providers and community organizations developed an electronic referral system to transfer clinical and insurance information from the ED to community clinics.

States, as part of Medicaid and other insurance coverage reforms, are also interested in encouraging the use of primary care providers instead of emergency departments. The Massachusetts universal coverage reform legislation included funding for Medicaid health plans to establish strategies to divert non-urgent patients away from EDs. These funds helped community health centers expand operations to offer appointments outside normal business hours. Florida also funds health centers to help cover the costs of treating uninsured patients, with some funding directed toward initiatives that encourage health center use over EDs for non-urgent care.

Ongoing Challenges

Safety net hospitals' efforts to limit ED use for non-urgent conditions face a number of obstacles. The amount of primary care available through clinics and health centers varies by community, and overall demand for care typically exceeds supply. Even as primary care capacity for low-income populations has expanded in some communities in recent years, ED directors reported significant waits for appointments at health centers and clinics, particularly for new patients and those needing specialty care.

Also, the challenge of redirecting patients is more complex than simply expanding health center and hospital clinic capacity. Some health centers' extended hours have not been utilized as predicted: a Miami health center started a pediatric clinic on Saturdays but discontinued it due to insufficient patient demand, and a Boston health center noted similar concerns about new Sunday hours. The reasons for low demand are not always clear, but community respondents pointed to limited transportation and child care, and suggested it takes time to inform people about health center options and encourage them to use those providers. Some low-income people still consider the ED their medical home. Additionally, hiring staff to redirect patients and investing in health information technology stretches safety net providers' limited budgets.

Furthermore, expanding access to primary care through community health centers and clinics often does not address the need for specialty, mental health, and dental care and prescription drugs, so many EDs continue to treat those needs on site. EDs often rely on specialists employed by the hospital or who are paid a stipend to serve on call to treat non-urgent patients while they are still in the ED.

Implications

Emergency departments provide important access for people whose conditions do not require immediate treatment but who cannot reach a community provider in a timely manner. However, EDs are not designed to manage ongoing, chronic needs, and wait times for care can be lengthy. Strategies and policies that help guide patients to other outpatient settings could improve access, enhance quality, and contain costs if there are community providers willing and able to treat more low-income people.

Findings across the 12 HSC communities suggest that a combination of approaches could help reduce ED use for non-urgent care, including expanding community health centers, community clinics, and hospital clinics and strategies to improve their accessibility. Aligning hours of operation and available services among existing providers could increase people's care options at lower costs. Since transportation is a significant barrier for some, bringing services to low-income neighborhoods through mobile vans and school-based services could improve access in a cost-effective way. Furthermore, incentives to improve communication and coordination among community providers and ED staff could facilitate referrals so care is provided in the most appropriate setting.

To encourage private practitioners to treat more low-income people, incentives such as enhanced Medicaid reimbursement appear essential. With the growth of Medicaid managed care, there is increasing pressure on Medicaid health plans to establish adequate networks of practitioners willing to treat Medicaid enrollees, but low payment rates to health plans lead to low payment rates to physicians. The Centers for Medicare and Medicaid Services, funded through the Deficit Reduction Act of 2005, awarded $50 million over two years to 20 state Medicaid programs to help build capacity and programs encouraging primary care use over ED use.

Moreover, low-income people need to be informed about alternatives to the ED. Previous research shows that most uninsured people are unaware of providers offering relatively low-cost care in their communities. Media campaigns and other outreach efforts could help raise awareness of health centers and hospital clinics, as well as the services offered and hours of operation. Incentives such as transportation vouchers and ensuring that patients pay less out of pocket for non-ED providers than they would in the ED could also encourage people to use other providers. The Deficit Reduction Act allows state Medicaid programs to permit EDs to charge copayments for non-urgent treatment, but the impact on ED use and whether needed care is obtained has yet to be determined.

Data Source

Approximately every two years, HSC conducts site visits to 12 nationally representative metropolitan communities as part of the Community Tracking Study to interview healthcare leaders about the local healthcare market, how it has changed, and the effect of those changes on people. The communities are Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y. The sixth round of site visits was conducted between February and June 2007 with 453 interviews. This Issue Brief is based on responses from CEOs and emergency department directors at the communities' main safety net hospitals, as well as directors of community health centers, local health departments, Medicaid agencies, and consumer advocates.

Sources and Further Reading

CDC National Hospital Ambulatory Medical Care Survey (NHAMCS) — Federal survey data on emergency department visit trends, patient acuity levels, and insurance status of ED patients cited in this research.

CMS EMTALA Fact Sheet — Centers for Medicare and Medicaid Services overview of the Emergency Medical Treatment and Labor Act, which requires hospitals to screen and stabilize all ED patients.

KFF: Medicaid and the Uninsured — Kaiser Family Foundation research on Medicaid managed care, coverage gaps, and ED utilization among low-income and uninsured populations.

AHRQ: Emergency Department Research — Agency for Healthcare Research and Quality resources on emergency department utilization, patient safety, and quality improvement strategies.

Commonwealth Fund: Safety Net Research — Research on safety net hospitals, community health centers, and strategies for improving access to care for low-income and uninsured populations.