Beginning next year, the Patient Protection and Affordable Care Act will expand insurance coverage to those currently uninsured, which will ultimately result in nearly 30 million newly insured Americans. Emergency departments account for approximately half of hospital admissions, according to a recent RAND Corp. report. This fact, combined with the potential for many hospitals to close under financial pressure from sequestration and reimbursement cuts, means EDs need to be prepared to manage an influx of visitors.
"With healthcare finances changing, some hospitals are not going to survive and will ultimately close, which is certainly going to put pressure on the remaining hospitals to best accommodate and take care of patients," says Patrick Broderick, MD, chair of the department of emergency medicine at Danbury (Conn.) Hospital, part of Danbury-based Western Connecticut Health Network. The hospital's ED currently sees approximately 70,000 patients a year, and the hospital expects this number to increase significantly in the next three to five years. Dr. Broderick describes the hospital's six-part plan for preparing to manage increased patient volume.
1. Facility expansion. One part of Danbury Hospital's plan to increase ED capacity is to expand its ED from approximately 20,000 square feet with 40 examination rooms to 40,000 square feet with 69 private exam rooms.
2. Streamlined patient flow. Danbury Hospital's ED is also changing patient flow to increase its ability to handle more patients faster. The ED will have a fast track area for patients with less urgent conditions so they can be seen expeditiously. Having separate areas for patients based on the urgency of their condition means patients with minor problems do not have to compete for a bed directly with patients who need immediate, life-saving attention, Dr. Broderick says.
The hospital is also shortening the intake process by bringing registration to the bedside. Normally, patients who enter the ED are evaluated by a triage nurse, register and wait to be seen by a provider. In the new process, ED patients will be brought to a bed directly after triage evaluation if beds are available. Patients are then registered at the bedside, and may even be registered after being seen by a physician. "Registration at the bedside eliminates the back-and-forth from triage to the waiting room to registration [back] to the waiting room," Dr. Broderick says. "It allows us to get the patients into the examination room that much sooner so the doctor can see them."
3. Case management. In addition to creating more physical space and changing patient flow, the ED is using case management to ensure patients receive care in the most appropriate setting. Since the ED involves many transitions in care — from home to the ED, from the ED to inpatient care, etc. — ED staff play a major role in connecting patients with the most appropriate care provider. Guiding patients through care transitions and preventing gaps in care benefit not only the patients who are transitioning, but also other ED patients, because a well-executed transition can prevent the need for a patient to return to the ED shortly after discharge. Fewer unnecessary ED visits means shorter wait times and less crowding.
To facilitate care transitions, Danbury Hospital staffs its ED with one case manager per shift. The case manager is responsible for ensuring patients are being sent to the most appropriate setting and coordinating services patients will need after they leave the ED. For example, the case manager may advise ED physicians on whether patients meet criteria for admission to inpatient care and may arrange any necessary home services for patients being discharged to home. "Being able to help facilitate services needed at home is essential because a lot of folks don't meet criteria to be in the hospital but need some type of home services," Dr. Broderick says.
4. Enhanced communication. Danbury Hospital's ED will enhance communication between the ED and outside providers, including transferring hospitals and primary care physicians, to ensure patients' transition in and out of the ED is smooth. For example, the ED established a portal to collect information from hospitals, skilled nursing facilities and other providers that are transferring patients to Danbury Hospital. Having this information allows ED staff to prepare for the incoming patient. In addition, the ED notifies the primary care physician as soon as a patient enters the department so the PCP is aware of the patient's situation.
After discharge, the ED communicates with patients' primary care physician or other post-ED care providers so the patient receives the appropriate follow-up care. The ED provides the post-discharge provider, whether a physician, skilled nursing facility or home care provider, with a copy of the patient evaluation, including the results of tests and recommended next steps. Communication during care transitions ensures patients receive the care they need and reduces the likelihood patients will need to return to the ED for the same complaint.
5. Expanded primary care relationships. Danbury Hospital and parent system Western Connecticut Health Network are working to build relationships with more primary care physicians to create capacity for more patients and more easily coordinate patients' transitions between the community and hospital. Western Connecticut Health Network has several models of physician relationships, including employment, a physician-hospital organization and more informal alignment strategies. The health system is working with its employed physicians in Western Connecticut Medical Group and independent physician practices to ensure they can accept referrals from the ED so patients can easily schedule follow-up visits and seek care in the most appropriate setting.
"We're making sure we have an adequate supply of primary care practices to be able to refer these patients, once they present to the ER, back to primary care so the next time they have a medical problem, they don't necessarily go to the ER because they have access to a primary care doctor," Dr. Broderick says.
6. Growth of non-physician provider relationships. In addition to partnering with primary care physicians, Western Connecticut Health Network and Danbury Hospital are building relationships with federally qualified health centers, non-profit clinics and other providers, such as nurse practitioners and physician assistants, to expand patients' options for care. "Leveraging non-physician providers is going to be extremely important in the future so patients are seen by the appropriate provider and have good follow-up so the illness doesn't worsen, requiring them to go back to the ER," Dr. Broderick says. "Trying to get people connected into the healthcare system, getting them engaged in preventive health and setting up transitions are going to be critical over the next couple years."
Patient-centered medical neighborhood
The hospital's efforts in preparing for an increase in patient visits align with the patient-centered medical home model, in which a team of primary care physicians coordinates care for the patient. Danbury Hospital is working to expand this model to a patient-centered medical neighborhood that has ED physicians, primary care physicians, specialists and other providers, according to Dr. Broderick. Under this model, providers will communicate with each other to facilitate handoffs and provide patients easy access to the care they need.
"At the core of it all is coordinating care across different providers and making sure the patient gets to the appropriate provider to receive care," Dr. Broderick says. "Good handoffs and good communication between providers — that's what successful organizations are going to do in the future."
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