Connecting uninsured patients to primary care could reduce emergency department use

For twenty years, use of hospital emergency departments has been on the rise in the United States, particularly among low-income patients who face barriers to accessing health care outside of hospitals including not having an identifiable primary health care provider. Almost half of emergency room visits are considered "avoidable." The Emergency Department-Primary Care Connect Initiative of the Primary Care Coalition, which ran from 2009 through 2011, linked low-income uninsured and Medicaid patients to safety-net health clinics.

"Our study found that uninsured patients with chronic health issues -- such as those suffering from hypertension, diabetes, asthma, COPD, congestive heart failure, depression or anxiety -- relied less on the emergency department after they were linked to a local health clinic for ongoing care," says Dr. Karoline Mortensen, assistant professor of health services administration at the University of Maryland School of Public Health and senior researcher. "Connecting patients to primary care and expanding the availability of these safety-net clinics could reduce emergency department visits and provide better continuity of care for vulnerable populations."

Funded by a grant from the Centers for Medicare & Medicaid Services and the Maryland Department of Health and Mental Hygiene, the initiative engaged all five of the hospitals operating in Montgomery County, Maryland at the time, and four safety-net clinics serving low-income patients. Using "patient navigators," individuals trained to help patients find the care they need and can afford, these hospitals referred more than 10,000 low-income, uninsured and Medicaid patients who visited emergency departments to four local primary care clinics, with the goal of encouraging them to establish an ongoing relationship with the clinic and reduce their reliance on costly emergency department care.

Two hospitals in Montgomery County who participated in the intervention continued the program after the initial grant period concluded because of the benefits they saw for patients and for reducing emergency department visits and associated costs. These hospitals are currently testing a new version of the intervention specifically deigned to link emergency department patients with behavioral health conditions to appropriate community-based services.

While hospital administrators and health policy experts throughout the country are recognizing that access to primary care improves continuity of care for patients and reduces avoidable use of emergency departments, the implications of this project are particularly important for hospitals in Maryland, which are now operating under a unique all-payer model for hospital payments. Within this new payment structure, Maryland hospitals will have to meet ambitious spending, quality of care, and population health goals. Reducing avoidable use of emergency departments can help in reaching these goals.

The project provides promise not only for hospitals in Maryland but throughout the nation to improve health care experiences and outcomes for their patients. Shared learning systems were an integral component of the project so participants were learning from each other and sharing best practices throughout the project and that learning has now been documented and can be replicated in other communities.

"This was an incredibly rewarding project to work on," says Barbara H. Eldridge, Manager of Quality Improvement at the Primary Care Coalition. "We created a learning system that permits us to sustain improved communication between patients and their providers, between hospital discharge planners and community based clinics, and across five hospitals operating in Montgomery County." The initiative has proven successful in Montgomery County, Maryland and is being replicated in communities in other parts of the country.