NHI Says Coordinated Care Can Reduce Disabled’s High ER Use; System Contains Many Barriers To Providing This Care

Working-age adults with disabilities account for a disproportionately high amount of annual emergency department visitors, reports a comparison study from National Institutes of Health (NIA)researchers. As emergency department care may not be the best to address non-urgent concerns and is higher in cost, finding a way to decrease these visits is of interest to many stakeholders.

The Study & Its Findings

One of the first detailed looks at this population’s heightened use of urgent care, the NIH study published online in Health Services Research on Dec. 26, analyzed pooled data from the Medical Expenditure Panel Survey.  . Researchers found access to regular medical care, health profile complexity and disability status contributed to people with disabilities’ use of the emergency department. To address this disparity, the authors recommend enhanced communication between emergency department and primary care physicians, and tailored prevention and primary care programs.

“We want to understand what takes people to the emergency department to learn if their care could be better managed in other ways,” said Elizabeth Rasch, Ph.D., chief of the Epidemiology and Biostatistics Section in the NIH Clinical Center’s Rehabilitation Medicine Department. “While many of those visits may be necessary, it is likely that some could be avoided through better information sharing among all of the health care providers who see a particular individual.”

The study found that despite representing 17 percent of the working age U.S. population, adults with disabilities accounted for 39.2 percent of total emergency room visits. Those with a severely limiting disability visited an urgent care department more often than their peers and were more likely to visit the department more than four times per year.

Emergency visits were also associated with poor access to primary medical care, which was more prevalent among adults with disabilities.

Rasch and her coauthors identified three nationally representative comparison groups — those without any self-reported mental or physical limitations, those with a limitation but who did not need daily living assistance, and those who did need assistance with daily living. Researchers evaluated access to medical care through self-reported survey answers to questions about attainment and delay of primary care services and prescription medications. The number of emergency department visits was also self-reported.

The authors — from the NIH Clinical Center and Brandeis University, Waltham, Mass. — made recommendations for provider and policymaker actions to offset some of the need for emergency care by individuals with disabilities. Prevention and chronic condition management programs tailored for the functional limitations and service needs of people with disabilities may help avoid a crisis situation that would call for an urgent care visit, the report noted. The authors also endorsed wider adoption of coordinated care systems for the disabled that provide case management, integration of psychosocial care and 24/7 access to medical assistance, among other services.

When a patient is admitted to the emergency department, sharing detailed medical information between emergency room and primary care staff could prevent repeat visits. Such coordination is particularly important for disabled patients as they may have limitations that interfere with medical self-advocacy and complex conditions that demand care from various providers.  “When a person has an emergency department visit, their primary care providers often don’t know or don’t get the results of that visit, and vice versa. The emergency department often doesn’t know about the complex medical history people bring with them,” Rasch said. “That’s where things tend to break down.” 

Improving Coordination Presents Big Challenges

While improved information sharing and communication between primary care and emergency room providers is a component of the answer, achieving this is not easy whether or not the patient is disabled. 

Communication and coordination issues are one of the leading challenges to the delivery of continuous care in the health care system, even where the patient isn’t disabled.  Depending on the condition of the disabled patient, cognitive, emotional, financial, home life or other conditions may further undermine the ability of the patient to mitigate these barriers through self advocacy.

In addition, the ad-hoc way in which  patients access emergency care and the possibility that patients access care based on proximity to care at the time of the emergency rather than based on affiliation with a “medical home” or other pre-planned source of care complicates establishment of reliable avenues for sharing information and records among providers. 

Furthermore, in today’s financial resource stretched health care environment, Medicare, Medicaid, Tricare, CHIP and private payers rarely make available any reimbursement to help physicians, hospitals and other health care providers defray the cost or finance resources needed to support this coordination.  Additionally, payers’ reimbursement models rarely allow for adjustment in periods of stay or other services when the disability or other conditions of the patient undermine assumptions that support early discharge to home or another environment.

Beyond these challenges, other factors also play a role.  Care coordination often is impacted by a range of other factors beyond the control of health care providers.  Disabled persons as well as other patients’ often are affected by educational, family, financial, psycho-social, cultural and other conditions beyond the ability of the health care provider to mitigate.

These and other realities create challenges to realizing the potential benefits that the NIH study suggests could be realized through proper care coordination.  Given the significance of the resources that the study reflects are consumed through the high ER use by persons with disabilities, however, payers, providers, community and government leaders and others should reconsider the appropriateness of current models and look for opportunities to adjust reimbursement and other practices to support proper care coordination and support for disabled and other individuals to mitigate the care and financial costs that result from penny-wise, pound foolish practices.

Have ideas or experiences that could help promote this goal.  Join the discussion and share your experiences in our LinkedIn group!

About Project COPE: The Coalition On Patient Empowerment & Its  Coalition on Responsible Health Policy

Sharing and promoting the use of practical practices, tools, information and ideas that patients and their families, health care providers, employers, health plans, communities and policymakers can share and offer to help patients, their families and others in their care communities to understand and work together to better help the patients, their family and their professional and private care community plan for and manage these  needs is the purpose of Project COPE:  The Coalition on Patient Empowerment, a community outreach project of theThe Coalition for Responsible Health Policy.

The Coalition for Responsible Health Care Policy and its Project Cope operate from the belief that thee best opportunities to improve access to quality, affordable health care for all Americans is for every American, and every employer, insurer, and community organization to seize the opportunity to be good Samaritans.  The government, health care providers, insurers and community organizations can help by providing education and resources to make understanding and dealing with the realities of illness, disability or aging easier for a patient and their family, the affected employers and others. At the end of the day, however, caring for people requires the human touch.  Americans can best improve health care by speaking  up, stepping up and taking the reins to control health care decisions and to help bridge the gap themselves rather than waiting for government or others to make decisions and take care of matters.  Building health care neighborhoods filled with good neighbors throughout the community is the key.

The outcome of this latest health care reform push is only a small part of a continuing process.  Whether or not the Affordable Care Act makes financing care better or worse, the same challenges exist.  The real meaning of the enacted reforms will be determined largely by the shaping and implementation of regulations and enforcement actions which generally happen outside the public eye.  Americans individually and collectively clearly should monitor and continue to provide input through this critical time to help shape constructive rather than obstructive policy. Regardless of how the policy ultimately evolves, however, Americans, American businesses, and American communities still will need to roll up their sleeves and work to deal with the realities of dealing with ill, aging and disabled people and their families.  While the reimbursement and coverage map will change and new government mandates will confine providers, payers and patients, the practical needs and challenges of patients and families will be the same and confusion about the new configuration will create new challenges as patients, providers and payers work through the changes.

We also encourage you and others to help develop real meaningful improvements by joining Project COPE: Coalition for Patient Empowerment here by sharing ideas, tools and other solutions and other resources. The Coalition For Responsible Health Care Policy provides a resource that concerned Americans can use to share, monitor and discuss the Health Care Reform law and other health care, insurance and related laws, regulations, policies and practices and options for promoting access to quality, affordable healthcare through the design, administration and enforcement of these regulations.

Other Helpful Resources & Other Information

We hope that this information is useful to you.   If you found these updates of interest, you also be interested in one or more of the following other recent articles published on the Coalition for Responsible Health Care Reform electronic publication available here, our electronic Solutions Law Press Health Care Update publication available here, or our HR & Benefits Update electronic publication available here .  You also can access information about how you can arrange for training on “Building Your Family’s Health Care Toolkit,”  using the “PlayForLife” resources to organize low cost wellness programs in your workplace, school, church or other communities, and other process improvement, compliance and other training and other resources for health care providers, employers, health plans, community leaders and others here. If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail by creating or updating your profile here. You can access other recent updates and other informative publications and resources.

Some examples of recent publications that may be of interest include:

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