Psychiatric Annals

CME Article 

Frequent Utilizers of Emergency Departments: Characteristics and Intervention Opportunities

Britta Ostermeyer, MD, MBA; Noor Ul Alien Baweja, BS; Bella Schanzer, MD; Jin Han, MD; Asim A. Shah, MD

Abstract

Patients who frequently use emergency departments (EDs) have been termed “frequent or high utilizers.” They disproportionally account for almost one-quarter of all ED visits and pose a tremendous socioeconomic and staff labor burden to health care systems. Although there is no agreed upon definition of how many ED visits define frequent use, this patient population shares common sociodemographic, diagnostic, and service use characteristics, in addition to high incidences of mental health and substance abuse problems. Various interventions have been successfully employed to reduce frequent ED visits. Case management (CM) is the most successful intervention. Although primary care access is a necessary element for EDs, successful reduction models must encompass additional interventions, including proper identification of frequent visitors, intensive CM with staff skilled in mental health and substance abuse interventions, partnership with community mental health and substance abuse treatment entities, and referrals to stable housing. This article reviews the common characteristics of ED frequent utilizers and reduction interventions. [Psychiatr Ann. 2018;48(1):42–50.]

Abstract

Patients who frequently use emergency departments (EDs) have been termed “frequent or high utilizers.” They disproportionally account for almost one-quarter of all ED visits and pose a tremendous socioeconomic and staff labor burden to health care systems. Although there is no agreed upon definition of how many ED visits define frequent use, this patient population shares common sociodemographic, diagnostic, and service use characteristics, in addition to high incidences of mental health and substance abuse problems. Various interventions have been successfully employed to reduce frequent ED visits. Case management (CM) is the most successful intervention. Although primary care access is a necessary element for EDs, successful reduction models must encompass additional interventions, including proper identification of frequent visitors, intensive CM with staff skilled in mental health and substance abuse interventions, partnership with community mental health and substance abuse treatment entities, and referrals to stable housing. This article reviews the common characteristics of ED frequent utilizers and reduction interventions. [Psychiatr Ann. 2018;48(1):42–50.]

Patients who use emergency departments (EDs) at disproportionately high rates are known as “frequent or high utilizers.”1,2 Although they constitute a smaller percentage of people visiting EDs, they account for approximately one-quarter of all ED visits and use a disproportionately high share of resources.1–5 Frequent utilizers are of great concern to EDs, hospitals, and health care systems at large.

Although there is no national or international standard definition of high ED use beyond the fact that these patients repeatedly present,1,4,6 it has been noted that they visit the ED more than once in a 4-, 6-, or 12-month period; more than 6 times in an indeterminate period; 6 or more times in a 12-month period; 4 or more times in a quarter; or with a frequency in the upper 10th percentile.1 The lack of a standard definition makes it difficult to compare ED data sets.

Frequent ED use has been labelled as nonemergent and inappropriate.2 Approximately one-third of ED visits are avoidable because the visit could have occurred in the primary care setting. These avoidable ED visits cost approximately $18 billion in health care expenses annually.7 Frequent utilizers often are of lower socioeconomic status, have many psychosocial issues, and may not have resources to pay for the high cost of ED service, thus imposing a substantial economic burden on health care systems.2,3,8–11 In addition, high ED utilizers are often uncooperative and threatening, which poses significant safety risks to ED staff.1,4 Frequent use contributes to ED overcrowding and occupies staff time, which can create emergency care access issues, delay in care, and compromise to patients in need,2 which reduces health care efficiency.

Due to the time and economic burdens placed on health care systems by frequent ED utilizers and to the fact that the needs of these patients who typically present in distress are not easily handled in the ED, it is important to identify common characteristics and problems that may result in frequent ED use. Identification of underlying issues may allow for interventions to be crafted for reducing this use.

Case management (CM), patient navigators, Internet-based multidisciplinary interventions, emergency medical service-based interventions, ED decision-support programs, individual patient care plans, patient education, peer counseling, drop-in group medical appointments, and partnerships with primary care or community mental health to facilitate outpatient appointment access have been used to reduce frequent ED visitations.1–5,7,12–17 In particular, intensive CM interventions have been shown to be successful at reducing visits as well as the associated costs.2,4,5,12,13

This article reviews the literature regarding frequent ED utilizers and reduction intervention programs. Additionally, we also present an illustrative case report and discuss recommendations for interventions.

Characteristics of Frequent ED Utilizers

Although the literature reports findings that are more unique to their respective patient populations, most studies identified common characteristics. Table 1 summarizes the common characteristics of frequent ED utilizers from this literature review.

Common Characteristics of Frequent Emergency Department Utilizers

Table 1:

Common Characteristics of Frequent Emergency Department Utilizers

Pasic et al.1 identified two subpopulations of high utilizers: (1) people with chronic, persistent, and severe mental illness who are enrolled in public mental health services, have housing, and exhibit aberrant behavior leading to hospitalization or incarceration; and (2) people who are acutely ill with a cluster of ED visits during which they tend to be homeless, unemployed, and unlikely to be enrolled in public mental health services.

Substance use and mental illness are commonly cited as risk factors for frequent ED use.1,2,8,9,14,18–21 Additionally, frequent utilizers more often have a history of psychiatric voluntary and involuntary hospitalizations, incarcerations, substance detoxifications, developmental delays, and personality disorders, and are more likely to be enrolled in public mental health services.1 Also, they are often more likely to be uncooperative, homeless, unemployed, and have poor social supports when compared to control ED patients.1,4

The systemic review of international health care systems by Soril et al.22 reported that being an ethnic minority and/or being uninsured was not a risk factor associated with frequent ED visits.22 They opined that, despite differences in financing and service provisions, frequent ED utilizers may not differ from one health care system to the next.

Mautner et al.23 identified three previously unknown risk factors for frequent ED use: (1) early life instability and trauma; (2) difficult interactions with health care providers; and (3) belief that a positive relationship with a health care provider is important.

Capp et al.18 found these key reasons for frequent ED use: (1) negative personal experiences with the health care system; (2) challenges of low socioeconomic status; and (3) significant chronic mental and physical disease burden. Patients in this study reported difficulties seeing their existing primary care physicians (PCPs) due to lack of transportation, insurance insecurity, and poor recall of primary care appointments. In a study with a homeless population, Thakarar et al.19 identified that hepatitis C predicted frequent ED visits. Sirotich et al.8 argued that the basic needs of food, shelter, psychosocial needs, and self-care were not independently associated with repeat ED use, but were strongly connected to issues related to psychosis, substance use, and safety risks (ie, suicidality).

Lam et al.9 found that patients with mental illness who also were homeless had higher 30-day ED and hospital return rates than patients who were home-based.9 Among patients with mental illness, being homeless contributed to an additional 28% increase in likelihood of 30-day ED revisits and 38.2% increase in likelihood of hospital readmission.9 In their Singapore-based study on frequent users of psychiatric EDs, Poremski et al.20 reported that the most commonly encountered patients presented with substance use or personality disorder, and/or were brought in by police. Although a sizable proportion of repeat utilizers had a diagnosis of psychosis, ED providers stated that psychosis was a more modest contributor than other factors to frequent ED use. This study further reported that frequent ED use was related to lack of social supports and a desire to belong and providers found it challenging to manage intoxicated patients, expectations for admission, and self-harm threats.20

Hunt et al.6 studied characteristics using a national, population-based data source and found that 8% of all patients were frequent users with four or more visits in a single year. Surprisingly, this study further found that most of these patients had insurance and a usual source of care but were more likely to be in poor health and seeking frequent medical attention.6

Frequent ED Utilizer Interventions

Many interventions to reduce repeat ED visits have been described, with CM being the most studied.2,5 Interventions can reduce visit frequency and associated health care costs; Table 2 summarizes reported interventions.

Interventions in the Literature for Frequent Emergency Department Utilizers

Table 2:

Interventions in the Literature for Frequent Emergency Department Utilizers

Pines et al.21 showed that Medicare beneficiaries who received care coordination at patient-centered medical homes were relatively less likely to use ED services. Although improved primary care experience with good appointment accessibility, care coordination, comprehensive care options, and integrated mental health and substance abuse services is helpful,10,21 arranging for primary care access alone is not sufficient to reduce use because frequent ED utilizers are often already receiving primary care services.11,24

Fredrickson et al.25 identified barriers to primary care access and lack of attention to preventive services as reasons for high ED use in Medicaid-insured children with asthma.25 Greater PCP accessibility including phone access, better care continuity, better adaptation to patient needs, more availability of urgent outpatient appointments, and less difficulties obtaining medications were identified as issues that would alter the rates of ED use among children with asthma. Furthermore, greater parental awareness of asthma risk factors and preventive strategies would have also reduced ED visit frequency.25

In 2017, Moe et al.3 published a systemic review on the effectiveness of interventions to decrease frequent adult ED visits. They reported great heterogeneity in the 31 studies that used interventions such as case management (n = 18), care plans (n = 8), diversion strategies (n = 3), printout case notes (n = 1), and social work visits (n = 1).3 Postintervention versus preintervention rate ratios were calculated for 25 studies and showed a significant ED visit reduction in 21 studies (84%).3 Studies addressing homelessness by using CM found consistent housing improvements. Fifteen studies evaluated hospital admission rates, and six of these demonstrated a decrease in admissions.3 Eleven of 13 studies concluded that interventions produced some direct or indirect savings. The authors concluded that interventions were effective in reducing ED visits.3

Raven et al.12 evaluated 38 studies, 13 of which were found to be of moderate or high quality using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria. They found that only CM consistently reduced ED use.12 In 2013, Kumar et al.2 published a systemic review on the effectiveness of CM in reducing frequent ED utilization; they also concluded that CM can improve both social and clinical patient outcomes. Some CM models included individual care plans and assertive and persistent outreach to assist patients in attending post-ED outpatient appointments.2

In addition, Kumar et al.2 reported that these studies also looked at different outcome measures, such as visit frequency, costs, or social variables, including housing, financial needs, or substance abuse. Among the 11 studies reporting ED use outcomes, eight reported a reduction in ED use ranging from 31% to 83%, two reported no significant reduction in populations with high ED overuse,26,27 and one reported an increase in ED use.28 Lee and Davenport26 failed to show an ED visit reduction in their study likely because the patients were largely homeless, uninsured, had high alcohol abuse rates, and high ED overuse with more than 3 monthly visits. Spillane et al.27 also failed to show a reduction in their study that focused on narcotic limitation and community referrals with patients who predominantly presented with pain and had more than 10 ED visits annually. Kumar et al.2 opined that CM interventions may be less effective in extreme, high ED utilizers as those patients may be more resistant to change and therefore may require more aggressive CM services than typical frequent utilizers. Phillips et al.28 showed an increase in ED utilization in a patient population mostly suffering from substance abuse and psychiatric disorders suggesting that CM may be less effective in this population.

Kumar et al.2 stated that the cost outcomes studies all reported cost reductions, with some also reporting a reduction in inpatient admissions. CM programs that successfully enrolled patients into housing showed a greater hospital cost reduction but no changes in cost were noted for medical outpatient, psychiatric inpatient, psychiatric emergency, or ambulance services.2

Overall, Kumar et al.2 judged the effect of CM on hospital admission reduction to be “disappointing.” Additionally, studies that assisted with homelessness, substance abuse, or financial needs demonstrated a reduction in those areas and an increase in health insurance, social security income, and financial means.2 One study2 demonstrated an 83% ED visit reduction and attributed this significant reduction to adequate PCP outpatient management and ED narcotic prescribing limitation. The same study also demonstrated a 67% reduction in ED computed tomography scan use, a 60% increase in ED visits with ongoing substance abuse, and a 69% reduction in ED visits after adjustment for substance abuse.2 CM was reported to improve PCP follow-up and community care appointments.2

CM was correlated with outcomes improvement and that patients who were more actively engaged with an understanding of follow-up goals, including how to take medications and how to make appointments, were less likely to have subsequent ED visits.2 Pertinent CM aspects were follow-up frequency after the initial interview, availability of psychosocial and substance abuse services, assistance with financial needs, and the aggressiveness of CM outreach to participants. CM plans that offered convenient meeting locations were reported to be more successful in reducing ED visits.2 Less aggressive CM plans that provided only PCP appointment referrals without ensuring actual appointment attendance were less successful, and a gradual transition toward giving patients more of an ownership in their care was reported to be associated with less ED utilization.2

In 2011, Althaus et al.5 presented a similar review and evaluated the effectiveness of frequent user interventions in 11 studies, 7 of which described a CM intervention. They also concluded that interventions may reduce ED use and that CM reduced ED costs and improved social and clinical patient outcomes. They also reported that CM is a worthy intervention in the framework of proper patient evaluation, which was suggested as more than four visits in 12 months.5

Enard and Ganelin15 evaluated a patient navigator program designed to promote appropriate community PCP use and reduce ED use. This patient navigation program reportedly lowered the ED return rate over a 12-month period by 46.4% in patients with one prior ED visit for a primary care need and by 36% in those patients who had two prior ED visits for a primary care need. However, the program did not lower ED return rate significantly over a 24-month period, and the authors suggested that the effect of the program may not be sustained over a long period.15 The authors also reported that the ED-associated cost savings were greater than the cost of the patient navigation program.15

Navaril-Strawn et al.7 implemented a cost-effective ED decision-support program that offered advice on treatment options, assistance in finding providers, and referrals to other health resources to a large group of insured patients. This decision-support program reportedly facilitated more appropriate levels of care, reduced ED visits and hospital admissions, and increased outpatient office visits, thereby saving $1.24 for every dollar invested in the program.7

Tadros et al.14 used an emergency medical services (EMS)-based CM and referral intervention program with adults who had ≥10 ED visits within 12 months. In approximately, 6 months, the following reductions were recorded: 37.6% in EMS encounters, 31.1% in EMS charges, 39.8% in EMS task time, 47.5% in EMS mileage, 28.1% in ED visits, 12.7% in ED charges, 9.1% in hospital admissions, and 5.9% in hospital costs.14 The referral intervention program case manager investigated factors underlying excessive acute care use, educated the high-utilizing patients about appropriate health care use, and connected them with community resources (primary care, mental health, social services, housing resources). This patient cohort reported a high prevalence of mental illness at 68.6%.14

Boudreaux et al.29 arranged for an outreach team from a community mental health center to meet patients in the ED and set-up care. These authors opined that such partnerships may improve patients' ED aftercare engagement and reduce return ED visits.29

Crane et al.17 reported a reduction in ED use and hospital charges (from $1,167 per month to $250 per month) in 255 uninsured frequent utilizers by combining cost-effective CM and drop-in group medical visits to provide care to patients with complex medical and social issues. Patients were also provided direct phone access to nurses, life skills and support group sessions, and individual short sessions if needed for a total annual program cost of $66,000.17

Pillow et al.4 developed a Internet-based, multidisciplinary care plan that reportedly decreased ED use, but not hospital admission rates, in 50 top ED users from 94 visits per month to 88 visits per month in a 15-month period. Patient care teams consisted of social workers, case managers, physicians, and members from key medical specialties routinely involved in the patient's care.4

Pugh et al.13 and Pope et al.16 used individual patient care plans to decrease the frequency of ED use. Pugh et al13 specifically addressed medical noncompliance, pain management demands, and disruptive behaviors via individual patient contracts, which outlined clear expectations to 42 patients when they presented for their ED visits. This decreased ED visits from 177 to 122 per year and decreased inpatient stays by 5.48%. Pope et al.16 reported a successful reduction in total ED visits from 616 per year (median 26.5) to 175 per year (median 6.5) in 24 patients who received individualized, multidisciplinary care plans focused on their needs and close follow-up for each ED visit.

Sirotich et al.8 studied 2,274 frequent psychiatric users with two or more psychiatric ED visits within the prior 6 months who were placed into intensive CM; they examined the unmet patient needs by condition-specific points.8 Repeat utilizers with mood disorders differed from those with psychotic disorders or those with mental illness and comorbid substance use. Over 6 months, approximately 6% of patients had two or more repeat ED visits. Repeat ED visitors were younger, had a mood disorder, were in the CM program less than 1 year, and had unmet needs related to psychotic symptoms, substance use, and safety to self/others. The authors concluded that unmet clinical needs rather than psychosocial needs had the greatest relationship with repeat psychiatric ED use, and that evidence-based therapies, such as cognitive-behavioral therapy (CBT) or dialectical-behavior therapy (DBT), may need to be added into CM services. The authors also emphasized addressing unmet substance use needs by increasing capacity to integrate substance abuse interventions within the CM team, by providing addiction and mental health services from the same team, and by using motivation-based intervention or multiple psychotherapeutic tools, such as motivational interviewing (MI), CBT, and group psychotherapy.8

A systemic review and meta-regression study by Burns et al.30 found that CM teams organized more like assertive community treatment (ACT) teams were better able to reduce hospital length of stays in patients with severe mental illness and that stays were also shorter when case mangers functioned as a team rather than independent practitioners. Drukker et al.31 found that symptom remission in patients with unmet needs related to psychosis was higher when flexible assertive community treatment (FACT) was used.

Illustrative Case

This is an illustrative case of a 45-year-old man with schizophrenia and poor medication compliance who typically presented to ED for exacerbation of auditory hallucinations 2 to 3 times a month for approximately 3 years. His laboratory tests showed uncontrolled diabetes, which usually required medical admission due to diabetic ketoacidosis. Although the patient was seen by his outpatient psychiatrist and his PCP for the past 2 years, his frequent ED use and hospital admissions did not subside. His average HbA1c level was 12%, and he exhibited signs of retinopathy and chronic kidney disease.

After his last ED visit, the patient was again admitted to the medical floor for initial medical management and subsequently transferred to the psychiatry inpatient unit for further stabilization. At that time, the patient was added to the list of high hospital utilizers and his case was discussed in the interdisciplinary inpatient team rounds. This team, comprised of social workers, an ED physician, an internist, a psychiatrist, and a resource coordinator, recommended the following individualized care plan: (1) begin injectable long-acting antipsychotic medication; (2) continue metformin and insulin; (3) enroll him in intensive CM services; (4) schedule a meeting with his family and engage them in his care; (5) provide him and his family education about his conditions and how to use medical services appropriately; (6) provide the patient and his family with the 24-hour nurse hotline number with instructions to report concerns prior to coming to the ED; and (7) schedule an outpatient follow-up visit in the integrated primary care mental health clinic within 1 week of discharge.

Unfortunately, the patient missed his scheduled integrated care appointment. His case manager contacted him to facilitate a new, expedited appointment; he was seen the following week. Although he did not report any recurrent psychotic symptoms, his blood sugar level showed early morning fasting values in the mid-300 mg/dL range and his metformin and insulin were adjusted. His return clinic appointment was scheduled for 2 weeks, at which time he was to receive the next long-acting antipsychotic injection.

The patient was stable psychiatrically over the ensuing 3 months. His repeat HbA1c level was 9%. He also received appointments for a flu shot, retinal scan, and podiatrist visit. In addition, the patient and his family met with the diabetes educator. He remained compliant with his monthly antipsychotic injections, and his repeat HbA1c result was less than 7% after 6 months. He missed two appointments during that time, but his case manager contacted him and arranged for new appointments. Over the subsequent 12 months, the patient only had one ED visit for new onset chest pain not requiring further hospitalization.

Case Discussion

Frequent utilizers of ED services often present with complex medical and psychiatric pictures compounded by poor social support systems and inadequate PCP and mental health service access. These problems are exaggerated when the care provided is not well coordinated and the health care team itself does not communicate about joint concerns regarding the patient. In this illustrative case, as was noted in many studies mentioned above, coordination of care together with intensive CM can reduce ED overuse and even lead to better patient health care outcomes.

In our illustrative case, the patient presented with a history of poor treatment adherence, both medical and psychiatric, despite attending outpatient appointments. This highlights the point made in the literature that connecting patients with outpatient care alone is not enough to prevent ED overuse. First, improved communication among the entire health care team was required, together with the awareness that this patient needed a new individualized and patient-centered approach. The acknowledgment of the problem by all health care team members is the first step in developing an appropriate intervention.

Second, through intentional education, the team empowered the patient and his family to take ownership of his disease process and made them engaged partners in care instead of only service recipients. This critical psychological shift serves to engage the patient in his or her health care, which is critical to improving adherence and reducing inappropriate ED use. In addition, for the first time, the team chose to initiate treatment with a long-acting medication injection ensuring medication treatment compliance. Once psychiatrically stabilized, our patient gained insight and judgment and was then able to engage and better comply with his other health issues.

Finally, and most significant, was the introduction of an intensive case manager into the patient's health care team. Although not definitive, the literature generally supports the finding that intensive CM leads to both a reduction in ED use as well as in overall health care costs and improved outcomes (although not formally discussed). This patient's experience underscored the power of coordinated care, including CM, to reduce inappropriate ED use and improve clinical outcomes for his diabetes.

Discussion of Intervention Opportunities

Our literature review yielded many articles describing the characteristics of frequent ED utilizers as well as intervention programs to reduce those visits.1–34 Unfortunately, effective interventions are not simply accomplished by creating more PCP outpatient capacity and referrals. Several studies have shown that heavy ED utilizers are also frequent users of other inpatient and outpatient medical services, including primary care.6,11,24 Although a health care system's primary care access is likely one of the most important elements,25 successful interventions require more than PCP accessibility.

On the other hand, it is important to identify inherent problems, such as lack of appropriate access to primary care, mental health, and/or substance abuse outpatient appointments, early on. Health systems may have to invest in integrated PCP accessibility with regards to mental health and substance abuse services. Shared and/or drop-in medical group visits have many advantages as well. In addition to improving care access, peer support, and patient engagement, they also empower patients to impart information to physicians.32 Interestingly, group visits can ease physician workload and lower health care cost while also increasing practice productivity.32 Vital community partnerships with mental health treatment entities can greatly improve patient accessibility to care. These partnerships can be even more effective by meeting patients at the ED to provide personalized follow-up appointments to mental health facilities.29

Preparation for interventions should begin with accurate and consistent identification of ED high utilizers to improve CM effectiveness.33 Proper identification requires knowledge of characteristics and ED use patterns. Wu et al.33 reported that routinely collected registration data can be effectively used to predict future frequent ED use. The authors emphasized that because many patients do not retain high ED utilization over time and may naturally reduce their visits without intervention, predicting which patients are likely to sustain high future use will be necessary for effectively improving health and reducing resource use in this vulnerable population. Also, when evaluating interventions, the regression to mean phenomenon should not be ignored.33 Additionally, acute episodic use needs to be distinguished from chronic overuse as those may largely be two different populations with different needs requiring potentially very different interventions.1,20

Next, it is important to evaluate the ED arrival mode for frequent utilizers.14,34 In case of a high rate of ambulance arrivals, it is crucial to involve EMS in the intervention program as they may represent a major ED port of entry.

Given that this population frequently presents with multiple and complex medical problems, psychiatric/substance abuse issues, psychosocial challenges, and is typically sicker than other populations, it is especially helpful to create individual patient care plans that address the patient's multiple needs. Many frequent users suffer from substance abuse and psychiatric disorders requiring more complex interventions.1,2,8–10,14,18–20,28,30,31 Unless case managers possess some mental health and substance abuse intervention skills, they may not be effective.8,28,30,31 Although patient/family education on illnesses, treatment planning, and appropriate health care use are key components, effective case managers also require additional skills in MI, CBT, DBT, ACT, and/or FACT.8,28,30,31 Individual care plans should also include stable housing referrals for homeless patients to successfully reduce ED overuse.9,19 Likewise, it is equally essential to address transportation issues to outpatient appointments and medication costs to prevent patients continuing to present to EDs for their medical and mental health needs.

Successful interventions must produce cost savings to health care entities; it is crucial to note the cost savings from decreased ED use as it relates to the expenses of the interventions. Table 3 summarizes suggested recommendations for interventions.

Recommendations for Emergency Department High Utilizer Interventions

Table 3:

Recommendations for Emergency Department High Utilizer Interventions

Conclusion

Frequent ED utilization poses a considerable burden on EDs and health care systems. High ED utilizers share common characteristics, including high rates of mental illness, substance abuse, and homelessness. Several successful interventions have been described in the literature. Proper identification of frequent visitors is one of the first steps. Successful intervention models require more services than just PCP referrals. Intensive CM to assist with patient/family education, mental health/substance abuse interventions, care coordination of outpatient primary care and mental health/substance abuse follow-up appointments, and social stressors, such as housing, transportation, and financial needs, emerged as the most effective intervention. It is also important to understand that unmet clinical needs rather than psychosocial issues can cause repeat ED use. Patients' needs are best met via individual patient care plans, inclusive of medical, psychiatric, substance abuse, and psychosocial interventions. In addition, successful intervention programs can yield net health care cost savings because they usually cost less than the money saved by reducing ED visitations.

References

  1. Pasic J, Russo J, Roy-Byrne P. High utilizers of psychiatric emergency services. Psychiatr Serv. 2005;56:678–84. doi:. doi:10.1176/appi.ps.56.6.678 [CrossRef]
  2. Kumar GS, Klein R. Effectiveness of case management strategies in reducing emergency department visits in frequent user populations: a systematic review. J Emerg Med. 2013;44(3):717–729. doi:10.1016/j.jemermed.2012.08.035 [CrossRef]
  3. Moe J, Kirkland SW, Rawe E, et al. Effectiveness of interventions to decrease emergency department visits by adult frequent users: a systematic review. Acad Emerg Med. 2017;24(1):40–52. doi:. doi:10.1111/acem.13060 [CrossRef]
  4. Pillow MT, Doctor S, Brown S, Karter K, Mulliken R. An emergency department-initiated, web-based, multidisciplinary approach to decreasing emergency department visits by the top frequent visitors using patient care plans. J Emerg Med. 2013;44(4):853–860. doi:. doi:10.1016/j.jemermed.2012.08.020 [CrossRef]
  5. Althaus F, Paroz S, Hugli O, et al. Effectiveness of interventions targeting frequent users of emergency departments: a systematic review. Ann Emerg Med. 2011;58(1):41–52. doi:. doi:10.1016/j.annemergmed.2011.03.007 [CrossRef]
  6. Hunt KA, Weber EJ, Showstack JA, Colby DC, Callahan ML. Characteristics of frequent users of emergency departments. Ann Emerg Med. 2006;48(1):1–8. doi:. doi:10.1016/j.annemergmed.2005.12.030 [CrossRef]
  7. Navaril-Strawn JL, Hawkins K, Wells TS, et al. An emergency room decision-support program that increased physician office visits, decreased emergency room visits, and saved money. Population Health Manage. 2014;117(5):257–264. doi:. doi:10.1089/pop.2013.0117 [CrossRef]
  8. Sirotich F, Durbin A, Durbin J. Examining the need profiles of patients with multiple emergency department visits for mental health reasons: a cross-sectional study. Soc Psychiatry Psychiatr Epidemiol. 2016;51:777–786. doi:. doi:10.1007/s00127-016-1188-5 [CrossRef]
  9. Lam CN, Arora S, Menchine M. Increased 30-day emergency department revisits among homeless patients with mental health conditions. West J Emerg Med. 2016;17(5):607–612. doi:. doi:10.5811/westjem.2016.6.30690 [CrossRef]
  10. Hudon C, Sanche S, Haggerty JL. Personal characteristics and experience of primary care predicting frequent use of emergency department: a prospective cohort study. PLOS One. 2016;11(6):e0157489. doi:. doi:10.1371/journal.pone.0157489 [CrossRef]
  11. Byrne M, Murphy AW, Plunkett PK, McGee HM, Murray A, Bury G. Frequent attenders to an emergency department: a study of primary health care use, medical profile, and psychosocial characteristics. Ann Emerg Med. 2003;41(3):309–318. doi:. doi:10.1067/mem.2003.68 [CrossRef]
  12. Raven MC, Kushel M, Ko MJ, Penko J, Bindman AB. The effectiveness of emergency department visit reduction programs: a systematic review. Ann Emerg Med. 2016;68(4):467–483. doi:. doi:10.1016/j.annemergmed.2016.04.015 [CrossRef]
  13. Pugh L, Duffy L, Stauss M. Patient care plans: An innovative approach to superusers in the emergency department. J Emerg Nursing. 2010;36(4):344–346. doi:. doi:10.1016/j.jen.2010.02.017 [CrossRef]
  14. Tadros AS, Castillo EM, Chan TC, et al. Effects of an emergency medical services-based resource access program on frequent users of health services. Prehosp Emerg Care. 2012;16:541–547. doi:. doi:10.3109/10903127.2012.689927 [CrossRef]
  15. Enard KR, Ganelin DM. Reducing preventable emergency department utilization and costs by using community health workers as patient navigators. J Healthc Manag. 2013;58(5):412–428. doi:10.1097/00115514-201311000-00007 [CrossRef]
  16. Pope D, Fernandes CMB, Bouthillette F, Etherington J. Frequent users of the emergency department: a program to improve care and reduce visits. CMAJ. 2000;162(7):1017–1020.
  17. Crane S, Collins L, Hall J, Rochester D, Patch S. Reducing utilization by uninsured frequent users of the emergency department: combining case management and drop-in group medical appointments. J Am Board Fam Med. 2012;25(2):184–191. doi:. doi:10.3122/jabfm.2012.02.110156 [CrossRef]
  18. Capp R, Kelley L, Ellis P, et al. Reasons for frequent emergency department use by Medicaid enrollees: a qualitative study. Acad Emerg Med. 2016;23:476–481. doi:. doi:10.1111/acem.12952 [CrossRef]
  19. Thakarar K, Morgan JR, Gaeta JM, Hohl C, Drainoni ML. Predictors of frequent emergency room visits among a homeless population. PLOS One. 2015;10(4):e0124552. doi:. doi:10.1371/journal.pone.0124552 [CrossRef]
  20. Poremski D, Kunjithapatham G, Koh D, Lim XY, Alexander M, Lee C. Lost keys: Understanding service providers' impressions of frequent visitors to psychiatric emergency services in Singapore. Psychiatr Serv. 2017;68(4):390–395. doi:. doi:10.1176/appi.ps.201600165 [CrossRef]
  21. Pines JM, Keyes V, van Hasselt M, McCall N. Emergency department and inpatient hospital use by Medicare beneficiaries in patient-centered medical homes. Ann Emerg Med. 2015;65(6):652–660. doi:10.1016/j.annemergmed.2015.01.002 [CrossRef]
  22. Soril LJJ, Leggett LE, Lorenzetti DL, Noseworthy TW, Clement FM. Characteristics of frequent users of the emergency department in the general adult population: a systematic review of international healthcare systems. Health Pol. 2016;120(5):452–461. doi:. doi:10.1016/j.healthpol.2016.02.006 [CrossRef]
  23. Mautner DB, Pang H, Brenner JC, et al. Generating hypotheses about care needs of high utilizers: lessons from patient interviews. Popul Health Manag. 2013;16(suppl 1):S26–S33. doi:. doi:10.1089/pop.2013.0033 [CrossRef]
  24. Hansagi H, Olsson M, Sjöberg S, Tomson Y, Göransson S. Frequent use of the hospital emergency department is indicative of high use of other health care services. Ann Emerg Med. 2001;37(6):561–567. doi:. doi:10.1067/mem.2001.111762 [CrossRef]
  25. Frederickson DD, Molgaard CA, Dismuke SE, Schukman JS, Walling A. Understanding frequent emergency room use by Medicaid-insured children with asthma: a combined quantitative and qualitative study. J Am Board Fam Pract. 2004;17(2):96–100. doi:. doi:10.3122/jabfm.17.2.96 [CrossRef]
  26. Lee KH, Davenport L. Can case management interventions reduce the number of emergency department visits by frequent users?Health Care Manag. 2006;25:155–159. doi:10.1097/00126450-200604000-00008 [CrossRef].
  27. Spillane LL, Lumb EW, Cobaugh DJ, Wilcox SR, Clark JS, Schneider SM. Frequent users of the emergency department: Can we intervene?Acad Emerg Med. 1997;4(6):574–580. doi:10.1111/j.1553-2712.1997.tb03581.x [CrossRef]
  28. Phillips GA, Brophy DS, Weiland TJ, Chenhall AJ, Dent AW. The effect of multidisciplinary case management on selected outcomes for frequent attenders at an emergency department. Med J Aust. 2006;184(12):602–606.
  29. Boudreaux JG, Crapanzano KA, Jones GN, et al. Using mental health outreach teams in the emergency department to improve engagement in treatment. Community Ment Health J. 2016;52(8):1009–1014. doi:. doi:10.1007/s10597-015-9935-8 [CrossRef]
  30. Burns T, Catty J, Dash M, Roberts C, Lockwood A, Marshall M. Use of intensive case management to reduce time in hospital in people with several mental illness: systematic review and meta-regression. BMJ. 2007;335(7615):336–340. doi:. doi:10.1136/bmj.39251.599259.55 [CrossRef]
  31. Drukker M, Maarschalkerweerd M, Bak M, et al. A real-life observational study of the effectiveness of FACT in a Dutch mental health region. BMC Psychiatry. 2008;8:93. doi:. doi:10.1186/1471-244X-8-93 [CrossRef]
  32. Stults CD, McCuistion MH, Frosch DL, Hung DY, Cheng PH, Tai-Seale M. Shared medical appointments: a promising innovation to improve patient engagement and ease the primary care provider shortage. Popul Health Manag. 2016;19(1):11–6. doi:. doi:10.1089/pop.2015.0008 [CrossRef]
  33. Wu J, Grannis SJ, Xu H, Finnell JT. A practical method for predicting frequent use of emergency department care using routinely available electronic registration data. BMC Emerg Med. 2016;16(12):2–9. doi:. doi:10.1186/s12873-016-0076-3 [CrossRef]
  34. Dinh MM, Berendsen-Russell S, Bein KJ, et al. Trends and characteristics of short-term and frequent representations to emergency departments: a population-based study from New South Wales, Australia. Emerg Med Aust. 2016;28:307–312. doi:. doi:10.1111/1742-6723.12582 [CrossRef]

Common Characteristics of Frequent Emergency Department Utilizers

<list-item>

Malea

</list-item><list-item>

Middle-aged or olderb

</list-item><list-item>

May be an ethnic minorityc

</list-item><list-item>

Medically and psychologically vulnerable

</list-item><list-item>

Unemployed

</list-item><list-item>

Medicaid or uninsureda,c

</list-item><list-item>

Homeless or housing instability, lack of transportation, or residing near the ED

</list-item><list-item>

Single, divorced, family disputes, social problems, or poor social supports

</list-item><list-item>

Early life instability or trauma history

</list-item><list-item>

More often come to ED by ambulance or police

</list-item><list-item>

May seek reprieve from stress or family may seek respite

</list-item><list-item>

Difficult health care provider interactions (negative health care experiences, belief that positive relationship with provider is important)

</list-item><list-item>

Prior ED/hospital admission (high utilizers of other medical services [inpatient and outpatient], accessibility and continuity)

</list-item><list-item>

Unmet health care needs in other medical settings or health care coordination problems

</list-item><list-item>

Higher disease burden (more complex, chronic, and uncontrolled disease with higher mortality)

</list-item><list-item>

Prior incarceration

</list-item><list-item>

Mental illness (often combined with medical/substance use disorders and/or homelessness)

</list-item><list-item>

History of psychiatric inpatient admissions

</list-item><list-item>

Substance use (history of detoxifications)

</list-item><list-item>

Chief complaint of pain and dental pain

</list-item><list-item>

Hepatitis C

</list-item>

Interventions in the Literature for Frequent Emergency Department Utilizers

<list-item>

Case-management program

</list-item><list-item>

Case management with MI, substance abuse, CBT, DBT, and/or ACT or FACT components

</list-item><list-item>

Patient navigators

</list-item><list-item>

Peer-to-peer counseling by state-certified community health workers

</list-item><list-item>

Internet-based ED-initiated, multidisciplinary program

</list-item><list-item>

Patient education on illness and appropriate medical service utilization

</list-item><list-item>

Emergency decision-support program

</list-item><list-item>

EMS-based case management and referral program

</list-item><list-item>

Individual patient care plans

</list-item><list-item>

Primary care referrals

</list-item><list-item>

Patient-centered medical home referrals

</list-item><list-item>

Community mental health referrals

</list-item><list-item>

Drop-in group medical appointment referrals

</list-item><list-item>

Housing referrals

</list-item>

Recommendations for Emergency Department High Utilizer Interventions

<list-item>

Identify frequent users with likely persisting high utilization

</list-item><list-item>

Identify ED arriving mode (EMS involvement)

</list-item><list-item>

If permissible, consider fees to access ED for low acuity medical problems

</list-item><list-item>

Identify users' characteristics, utilization pattern (acute/periodic vs chronic), and needs

</list-item><list-item>

Identify underlying system's problems conducive to high utilization

</list-item><list-item>

Interdisciplinary, individual care plans targeting patient's specific needs

</list-item><list-item>

Intensive case management with staff training in MI, CBT, ACT, and/or FACT 24-hour nurse hotline access

</list-item><list-item>

Patient/family education on illness, treatment plan, and appropriate health care utilization

</list-item><list-item>

PCP accessibility with integrated mental health/substance abuse services

</list-item><list-item>

Consider drop-in group medical visits

</list-item><list-item>

Mental health and substance abuse accessibility (consider partnerships with community treatment entities)

</list-item><list-item>

Stable housing referrals

</list-item><list-item>

Transportation to outpatient appointments

</list-item><list-item>

Financial needs (including costs for health care and medications)

</list-item>
Authors

Britta Ostermeyer, MD, MBA, is the Paul and Ruth Jonas Chair in Mental Health and Professor and Chairman, Department of Psychiatry and Behavioral Sciences, University of Oklahoma Health Sciences Center. Noor Ul Alien Baweja, BS, is a Graduate, University of Houston. Bella Schanzer, MD, is an Associate Professor and the Vice Chair of Clinical Affairs, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine. Jin Han, MD, is an Assistant Professor of Psychiatry, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine. Asim A. Shah, MD, is a Professor and the Vice Chair for Community Psychiatry, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine; and the Chief of Psychiatry, Ben Taub Hospital, Harris Health System.

Address correspondence to Britta Ostermeyer, MD, MBA, Department of Psychiatry and Behavioral Sciences, University of Oklahoma Health Sciences Center, 920 Stanton L. Young Boulevard, Oklahoma City, OK 73104; email: Britta-Ostermeyer@ouhsc.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20171206-02

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