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ed utilization

Implications and Solutions for Emergency Department Overutilization

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According to the CDC, there are over 130 million Emergency Department (ED) visits each year, with over 16.2 million resulting in admission to the hospital. The Centers for Medicare and Medicaid Services say that one of the goals of primary care should be to reduce unnecessary emergency department utilization—defining unnecessary as those that could be handled in a primary care setting or prevented altogether. However, the effective reduction of ED utilization is complex and multifactorial, requiring numerous approaches of interventions to care.

Effective care management is one of the best ways to identify patients at risk for frequent trips to the ED. Care management is a process by which a care manager reaches out and oversees patients —for their benefit. The process helps patients remain engaged with their provider, preventing gaps in continuity of care and ultimately lowering ED utilization.

Improving a Patient’s Access to Care Avoids Unnecessary ED Utilization

Enhancing access to a provider helps patients feel at ease and promotes the patient-centered care model. Each practice can take different steps to ensure that patients are encouraged to share what is going on with their health. By employing different tactics, such as guidance about emergent care through a nurse line, medication advice, or preventative care management, practices help their patients avoid the ED.

Care managers don’t just help identify patients, but also intercede for the benefit of the patient, preventing patients from severe health complications. The relationship formed between a care manager and patient builds trust. This trust allows patients to gain a better understanding of their health while also forming an important bond. Patients with access to their care managers will trust them more, which helps lead to early identification and triage of health issues. By identifying health issues before they are exacerbated, care managers can step in and help the patient avoid the emergency department.

Additionally, care managers can help by providing regular contact with patients through personal contact and Remote Patient Monitoring (RPM). RPM platforms help by reaching out on a schedule, collecting data, and then using that data to inform care managers when rising-risk or high-risk patients are in need. Since some patients face issues with transportation, lack of childcare, or other barriers of access—nurses, care managers, and social workers can all participate in telehealth and/or home visits to prevent gaps in care and help prevent ED visits.

Improving Patient Education and Wellness

Understanding why patients use the ED will help any provider’s practice find approaches to solve the issue of unnecessary ED utilization, especially if there is a high patient population that has inequality of access to care. More often, communicating with patients will improve their overall health or let them know their options outside of the ED. Sometimes patients are unaware that better options exist than the ED.

Patient wellness is another area to ensure that patients are being cared for. Care managers can look at patient records to ensure each patient receives an annual wellness visit ensuring care is preventative rather than reactive. In doing so, providers mitigate risk for those patients and prevent ED visits.

Cost Benefits of Reducing ED Utilization

While preventing unnecessary ED utilization benefits practices by improving returns on investment through Medicaid, Medicare, and commercial insurance, it’s important to note that it’s also about improving patient health and patient communication. When you have the right care at the right level, practices and providers will always see good financial outcomes.





By Jessica Scruton, BSN, RN, CCM-R,
VP of Clinical Transformation

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