Failing to address unmet needs and difficulty navigating the health system are two primary forces driving repeat ED use. Unmet needs after an ED visit range from poorly controlled chronic diseases to incomplete understanding of new medications or follow-up instructions. Perceived barriers to access to primary care and other services are also cited as factors that lead Veterans back to the ED for ambulatory care.
Improving access to services and care coordination are among the primary goals of the Veterans' Health Administration's (VHA) ongoing reorganization of primary care. Patient Aligned Care Teams (PACTs) have been created in VAMCs across the country; however, there has been little focus on the interface between PACT and the ED. A key role for nurses within PACT is telephone management of high risk populations, and Veterans treated and released from the ED represent one such high-risk group. However, few studies have examined both the Veteran and system-level impact of using nurse care managers to support Veterans after an ED visit.
The overall goal of this study was to examine the impact of a primary care-based nurse telephone support program for Veterans treated and released from the ED who were at high risk for repeat visits. The investigators tested the following hypotheses:
H1: Veterans who participate in a primary care-based nurse telephone support program after an ED visit will have fewer ED visits in the subsequent 30 days compared to usual care;
H2: Veterans who participate in a primary care- based nurse telephone support program after an ED visit will have higher satisfaction compared to usual care;
H3: Veterans who participate in a primary care-based nurse telephone support program will have lower VA costs for ED and hospital care in the 180 days following an ED visit, compared to usual care.
The study was a two group randomized, controlled trial to evaluate a structured nurse telephone support program for Veterans treated and released from the ED who were at high risk for repeat visits. High risk was defined by presence of 2 chronic conditions and 1 ED visit or hospitalization during 6-months prior to index ED visit. Participants were randomized 1:1 to the intervention group or usual care. The intervention consisted of two core calls within seven days of the index ED visit with optional calls as needed for up to 30 days. The first call addressed transitional care and the second focused on case finding and referral for chronic disease management programs. The primary outcome was repeat ED use at 30 days. Secondary outcomes were patient satisfaction with VA health care at 30 and 180 days, and total VA costs within 180 days. We also examined primary care, mental health, chronic disease management services, and ED use and hospitalization at 180 days. Differences in rates between groups were examined using multivariable logistic and negative binomial regression models adjusted for having >3 ED visits prior to study index ED visit ("ED super-user"). We reported odds ratios (OR) and 95% confidence intervals (CI).
Five hundred thirteen "high risk" Veterans with a VA ED visit between 03/10/2014 and 01/25/2016 were enrolled (n= 257 DISPO ED, n= 256 usual care). The mean age of participants was 59.1 years; 22.2% were female, and 49.6% were Black. Just over a quarter (26.5%) were ED super-users, and 40.2% reported high psychological distress at enrollment. Nearly all (98.1%) of intervention participants completed both core calls. Total intervention time averaged 39.5 minutes/participant. H1: Observed rates of repeat ED use at 30 days in usual care and intervention groups were 23.1% and 24.9%, respectively (no difference between groups; OR=1.1; 95% CI =0.7,1.7; P=0.6). H2: There were no between-group differences at 30 or 180 days in patient satisfaction with VA health care. H3: There was no statistically significant mean difference in VA costs in the 180 days following an ED visit between the intervention and usual care group (n = 5,993; 95% CI= -2,995, 15.158; p=0.07).
The intervention group had a higher rate of having at least 1 primary care visit at 30 days (OR=1.6, 95% CI=1.1-2.3). At 180 days, the intervention group had a higher number of primary care visits per patient (incidence rate ratio=1.2, 95% CI=1.0-1.3), a higher rate of usage of MOVE!, a weight management program (OR= 3.5, 95% CI=1.6-7.5), Diabetes or Nutrition services (OR=1.8, 95% CI=1.0-3.0), and Care Coordination and Home Telehealth services (OR=1.7, 95% CI=1.0-2.9) compared to usual care. There were no between group difference in mental health visits or at 180 days in ED and hospital use, use of medication management, sleep medicine, rehabilitation or orthopedic services. Future analyses will examine subgroups such as race, age, gender, high mental distress, financial insecurity and ED Super User status as potential treatment moderators.
A brief, nurse-led telephone support program after an ED visit increased engagement with primary care and chronic disease management services such as weight management/exercise programs, Diabetes services and telehealth-based care coordination but did not increase patient satisfaction with VA health care or reduce repeat ED visits or hospitalizations at 30 or 180 days. Enhancing interventions to address high levels of psychological distress in high risk populations may be a fruitful avenue for future study.
- Hastings SN, Stechuchak KM, Coffman CJ, Mahanna EP, Weinberger M, Van Houtven CH, Schmader KE, Hendrix CC, Kessler C, Hughes JM, Ramos K, Wieland GD, Weiner M, Robinson K, Oddone E. Discharge Information and Support for Patients Discharged from the Emergency Department: Results from a Randomized Controlled Trial. Journal of general internal medicine. 2020 Jan 1; 35(1):79-86.
- Hwang U, Hastings SN, Ramos K. Improving Emergency Department Discharge Care with Telephone Follow-Up. Does It Connect? Journal of the American Geriatrics Society. 2018 Mar 1; 66(3):436-438.
- Miller KEM, Duan-Porter W, Stechuchak KM, Mahanna E, Coffman CJ, Weinberger M, Van Houtven CH, Oddone EZ, Morris K, Schmader KE, Hendrix CC, Kessler C, Hastings SN. Risk stratification for return emergency department visits among high-risk patients. The American journal of managed care. 2017 Aug 1; 23(8):e275-e279.
- Whitson HE, Johnson KS, Sloane R, Cigolle CT, Pieper CF, Landerman L, Hastings SN. Identifying Patterns of Multimorbidity in Older Americans: Application of Latent Class Analysis. Journal of the American Geriatrics Society. 2016 Aug 1; 64(8):1668-73.
- Hastings SN, Betts E, Schmader KE, Weinberger M, Van Houtven CH, Hendrix CC, Coffman CJ, Stechuchak KM, Weiner M, Morris K, Kessler C, Oddone EZ. Discharge information and support for veterans Receiving Outpatient Care in the Emergency Department: study design and methods. Contemporary clinical trials. 2014 Nov 1; 39(2):342-50.
- Hughes JM, Freiermuth CE, Williams JW, Ragsdale L, Eucker S, Goldstein K, Rodriguez R, Fulton J, Hastings SN, Shepherd-Banigan M, Ramos K, Tabriz AA, Gordon AM, Gierisch JM, Kosinski A, McDuffie J, Van Noord M. Emergency Department Interventions for Older Adults. VA Evidence-based Synthesis Program Reports. Washington (DC): Department of Veterans Affairs (US); 2018 Jun 1.
- Wilkerson LM, Owenby R, Bryan W, Moss J, Jackson GL, Van Houtven CH, Wilkerson MD, Stevens M, Vaughn C, Powers J, Huang U, Hung U, Markland A, Hastings SN. An Interdisciplinary Academic Detailing Approach to Decrease Inappropriate Medication Prescribing for Older Veterans Treated in the Emergency Department. Poster session presented at: American Geriatrics Society Annual Meeting; 2015 May 15; National Harbor, MD.
Quality of Care