Background: Emergency room crowding has been proven to lead to poor outcomes (e.g., mortality) and has worsened during the COVID-19 pandemic. Novel clinics that work collaboratively with emergency departments (ED) to transfer lower acuity patients to receive care in ambulatory settings rather than the ED have emerged. Our innovative ED Surge program cares for these triaged patients in an on-site, same day ambulatory setting and pairs eligible patients with patient advocates to aid in establishing continuity of care. We set out to study the impact of this ED Surge program on acute care utilization and continuity of care.
Methods: Our ED Surge Program was implemented in our Care Transitions Clinic (CTC). Advanced practice nurses screen for eligible ED patients based on their acuity and reason for visit. Patient advocates see patients without primary care clinicians to connect them to longer-term continuity of care. Data was collected on completed visits, patient demographics, insurance status, primary care clinician status, post CTC ED visits and hospitalizations within the study period, and visit diagnosis (type, severity). Group differences were evaluated with Chi-squared tests, one-sided t-tests, and multivariate analysis (p<0.05).
Results: From March-October 2021, 264 patients were referred to the CTC for 284 visits with 210 (74%) completed visits. Most patients were female (n= 142; 55%) and Black (n=228; 88%), with a mean age of 36.4 years (SD=15.3; range 18-93). Most patients had Medicaid (59%), followed by private insurance (15%), no insurance (14%), and Medicare (13%). A majority (222; 86%) did not have an existing primary care clinician; patient advocates were able to see nearly one-fifth of these patients (27; 17%). The most common reason for visit was respiratory symptoms (upper respiratory, cough, COVID exposure/diagnosis; 51; 25%); followed by sexually transmitted infections (36; 18%), other infections (34; 17%), and sickle cell pain crises (25; 13%). Of 210 patients, 60 (28%) had ED visits and 26 (12%) had hospitalizations after their clinic visit. The two groups (completed visit vs. not completed) were similar except those who completed visits were younger (p=0.03), more likely to have Medicaid, and less likely to be uninsured (p=0.01). With results approaching significance, those who completed their clinic visit (vs. not completed) were more likely to revisit the ED (p=0.08), but less likely to be hospitalized afterwards (p=0.06). There were no differences by diagnosis or severity for ED and/or hospitalization revisits (p>0.05), though results signal a potential association for patients with Medicaid using the program for less severe diagnoses (p=0.07).
Conclusions: Our program aims to improve care efficiency for lower-acuity patients and builds upon existing “surge” programs by incorporating patient advocates to help establish care continuity with primary care clinicians. While patients who visited our clinic did not differ significantly in repeat ED visits, hospitalizations, or acuity, our follow-up time to date has been relatively short. We aim to continue to expand our analysis to understand further the impact of our clinic on acute care utilization and improvements in continuity of care.