Background:

Numerous research studies and anecdotal experience show that in health care, a small percentage of patients account for a disproportionate number of ED visits and hospital admissions. For some of these patients, their visits are routinely for medically unnecessary reasons. This behavior places them at risk for uncoordinated care from providers who don’t know them and drives up healthcare costs without improving quality. Common reasons for unnecessary visits include 1) narcotic–seeking behavior, 2) mental health diagnoses, and 3) medical noncompliance. We started a Care Plan Committee, composed of leaders from Nursing, Quality, Pharmacy, Care Management, Hospital Medicine, Emergency Medicine, and Risk Management, to create care plan templates that could be used for high risk patients.

Purpose:

To see whether the use of restriction care plans for high risk patients could reduce the rate of medically unnecessary hospital admissions and ED visits.

Description:

We created two care plan templates (Narcotic restriction and Hospital Medicine/ED care plans) that could be placed on high risk patients. The templates were then entered into our EMR. Patients deemed good candidates for care plans were chosen by HM and ED providers, care management staff, and nursing. All departments received education on how to implement the care plans. Providers were strongly encouraged to tailor the templates for each individual patient. These care plans were then entered into the patient’s EMR, and could be easily seen by any future provider when logging into the patient’s chart, whether in the hospital, ED, or primary care clinic. Primary care providers were included in care plan creation when possible, and at a minimum, were sent copies of their patient’s care plans via the EMR.

Conclusions:

To date, there have been 15 restriction care plans placed on patients. In the 2 months prior to care plan implementation, these patients accounted for 78 ED visits and 37 admissions. In the 2 months after care plans were placed, these numbers dropped to 28 ED visits and 7 admissions. This represents a 70% reduction in total ED visits and admissions. Our care plans improved safety and continuity of care, especially for patients with narcotic–seeking behavior, while reducing unnecessary use of healthcare resources. The response from physicians and nurses has been overwhelmingly positive.

Partial Text From Narcotic Restriction Care Plan

In an attempt to maintain good consistency and quality of care, and maintain your safety when you are seen by providers who may not know you well, we are going to institute the following care guidelines:
Patient is not to receive IV narcotics in the ED unless there is a medical emergency unrelated to chronic pain.
The Emergency Room is not to be used for routine medical care or management of your chronic pain. Instead, we will help set up more frequent visits with your clinic team of providers.
There will be NO filling of oral narcotics at the time of discharge by the ED or inpatient providers.
IV Benadryl and IV Benzodiazepines should not be used for pain control.
Repeated use of imaging studies (ex—CT scans) which puts you at risk for radiation exposure will be discouraged unless exam, vital signs, and/or screening labs are highly suggestive of new pathology.
We will offer substance–abuse treatment programs when appropriate.
For chronic pain, or exacerbations of chronic pain, the patient’s outpatient regimen should be used.