The Efficacy of Case Management on Emergency Department Frequent Users: An Eight-Year Observational Study

The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–10, 2016 Ó 2016 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2016.06.002

Administration of Emergency Medicine

THE EFFICACY OF CASE MANAGEMENT ON EMERGENCY DEPARTMENT FREQUENT USERS: AN EIGHT-YEAR OBSERVATIONAL STUDY Casey A. Grover, MD, Elizabeth Crawford, BS, and Reb J. H. Close, MD Division of Emergency Medicine, Community Hospital of the Monterey Peninsula, Monterey, California Reprint Address: Casey A. Grover, MD, Division of Emergency Medicine, Community Hospital of the Monterey Peninsula, 23625 Holman Highway, Monterey, CA 93940

, Abstract—Background: Case management is an effective short-term means to reduce Emergency Department (ED) visits in frequent users of the ED. Objectives: Our study aimed to assess the long-term efficacy of intensive case management in frequent users of the ED. Methods: This was an observational study of ED usage conducted at a community hospital that has an ED case management program in which frequent users of the ED are enrolled and provided with intensive care management to reduce ED use. Results: We identified 199 patients that were enrolled for 6 or more years. Patients averaged 16 visits per person per year in the year prior to enrollment. Patients averaged the following number of visits per person per year after enrollment: year 1 (7.1), year 2 (4.1), year 3 (3.1), year 4 (3.3), year 5 (3.1), year 6 (2.0), year 7 (2.1), and year 8 (1.9), all statistically significant compared to the year prior to enrollment. Twenty-nine patients, despite case management, continued their frequent use, and required a revision to their plan of care. Five patients required a second revision to their plan of care secondary to recurrent ED usage. Persistent use despite case management was primarily due to prescription medication misuse and chronic pain. Conclusion: Case management of ED frequent users seems to be an effective means to reduce ED usage in both the short and long term. Patients with prescription drug misuse or chronic pain may continue to demonstrate frequent use despite case management, and may require revisions to their plan of care. Ó 2016 Elsevier Inc. All rights reserved.

INTRODUCTION Frequent users of the Emergency Department (ED), a heterogenous group of patients who overuse ED resources, have become increasingly common in United States (US) EDs. Such patients may account for as many as 28% of all ED visits, and the number of annual visits by frequent users is continually rising (1–4). Initial studies of frequent users defined this group of patients as making four or more visits to the ED annually; however, subsequent studies have demonstrated that frequent users may be better separated into those patients with less frequent (<10 visits per year), frequent (10–20 visits per year), and highly frequent (20 + visits per year) use patterns (2–8). Frequent users, furthermore, tend to have a high burden of chronic illness, substance abuse, and psychiatric illness (2–4,6–10). As frequent users of the ED usually visit multiple hospitals, disproportionately use Emergency Medical Services, and tend to have multiple medical and psychiatric comorbidities, this group has been shown to increase both health care costs and ED crowding (5,7,11–17). To reduce excessive use of the ED by such patients, case management has been employed as a means to reduce ED visits by frequent users, and has been found to be effective in reducing the number of visits as well as the cost of care in this population (5,12,16,18,19). Despite the heavy burden that frequent users of the ED place on

, Keywords—emergency department; case management; frequent users

RECEIVED: 27 May 2015; FINAL SUBMISSION RECEIVED: 16 September 2015; ACCEPTED: 2 June 2016 1

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the health care system and the well-described effect of case management to decrease ED use, studies of the effect of case management have consisted of relatively small groups of patients over short periods of time, such as 1 to 2 years (19–21). To the best of our knowledge, there have been no studies to date evaluating the efficacy of case management on ED frequent use in the long term. The objectives of this study were to evaluate the longterm effectiveness of case management in reducing ED usage by frequent users in a large group of patients over a multi-year period. We sought to evaluate whether or not the effect of case management in reducing ED use would persist after multiple years in the case management program. We also sought to determine whether or not patients would require revisions to their initial case management plan as their medical conditions and relationship with the ED changed over time. MATERIALS AND METHODS The study was conducted at a 258-bed suburban hospital on the West Coast, with an annual ED census of approximately 50,000 patients per year. The study was granted institutional review board exemption by the hospital committee on research. In February of 2006, the staff of the ED identified a group of patients exhibiting frequent ED usage, and created a case management program to help reduce visits by these patients. This program is managed by ED nurses as well as registered nurse (RN) case managers, and is additionally staffed by several emergency physicians, a chemical dependency physician, social workers, and representatives from local Medicaid services. The group meets once monthly, and reviews ED use patterns and behaviors by patients to determine the underlying issues behind a patient’s recurrent ED use–such as uncontrolled diabetes, prescription drug addiction, or lack of primary care. A plan of care (POC) is then developed for the patient to help correct this problem, and the POC is placed in the patient’s permanent medical record as well as shared with the patient himself or herself and all his or her physicians and other health care providers. When a patient in the program arrives in the ED, treating ED providers are alerted that the patient is in the case management program on the electronic track board, and providers are easily able to review the patient’s POC. Care plans are designed for each patient based on his or her chronic medical problems and reasons for repeat ED usage. Examples of care plans include restricting the prescription of pain medication refills for chronic problems, referral to ancillary services such as physical therapy, referral to primary care, and referral to social work. A POC for a patient is considered a guideline for optimal care for a patient to prevent recurrent ED visits

for chronic problems. Patients presenting to the ED with an acute problem such as a fracture or acute infectious illness are treated as any other acute patient, keeping in mind chronic medical problems listed in the patient’s POC. Care plans, furthermore, are considered guidelines–and care providers in the ED can deviate from the plan if felt to be medically necessary. A sample POC can be seen in Figure 1. To determine the effect of case management on ED utilization in the long term, we performed a chart review and reviewed all visits by patients in the case management program who had been in the program for 6 or more years. Beginning with the year prior to enrollment in the program, we reviewed all visits through December 2014. We recorded the number of visits per year for each year in the program as well as the year prior to enrollment in the program to determine whether or not case management was able to reduce ED usage, and also to determine whether or not the effect of case management on ED usage was persistent over time. In response to changes in patient usage of ED services as well as the changes in patients’ medical conditions over time, ED staff, hospital or clinic physicians, or the patient himself or herself may suggest that the POC for a patient is no longer appropriate and needs to be revised. In this case, the patient’s ED usage and original POC is re-reviewed by the case management team, and a new POC is created to replace the previous. This new POC is distributed to providers and the patient in the same fashion as the initial plan, and is placed in the medical record, listed as a revision to the original plan. In patients who required a revision to their POC, we recorded all visits in the 1-year period prior to and after the revision to evaluate the effect of the revision on ED use. Furthermore, to determine the need for revision, we recorded what changes were made. Over the 8-year time period during which the case management program has been in existence at our institution, the referral criteria for enrollment in case management has changed as the program has become more robust and well defined. Initially, patients were enrolled in the program if they had five or more visits in a 1month period, if they were reported by the California Prescription Drug Monitoring Program as demonstrating problematic prescription drug use, or if an ED staff member expressed concern over problematic ED use. As the program has evolved with time, the number of visits per month triggering a patient to be enrolled in the program has become any of the following: four visits in a 1month period, six visits in a 3-month period, or 12 visits in a 12-month period. The goal of our investigation was to evaluate the effect of the case management program over a long period of time, which to the best of our knowledge has not yet

The Efficacy of Case Management on ED Frequent Users

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Paent Name / DOB

Sample Paent

MRN / Insurance

******

Primary MD

John Doe, MD

Other MDs

University Neurology Clinic

Summary

Medicaons

This 25 year old male was referred for frequent visits for migraine headaches. He has 12 visits in 12 months and frequently receives Dilaudid, Toradol and Phenergan. He is seen by the University Neurology Clinic and receives nerve block treatments. We reviewed state prescripon drug record which shows mulple prescribers for narcocs. We reviewed safe pain medicaon prescribing and advised him that his pain prescripons need to come from one provider. Imitrex, Norco, Excedrin

Allergies

Penicillin

Health Problems

Chronic Migraine headaches since childhood

Plan of Care

01/01/1990 Medicare 1-800-111-1111

1. While in the Emergency Department the paent will not receive opiates, benzodiazepines, or other sedang medicaons such as SOMA or muscle relaxants unless there is evidence of a medical or surgical emergency. 2. The paent will not receive discharge prescripons for opiates, benzodiazepines or other sedang medicaons such as SOMA or muscle relaxants from the Emergency Department. 3. Encourage paent to aend the Hospital Chronic Pain Support Group which meets every Wednesday from 10am to noon. The paent may call the hospital for registraon and more informaon. 4. Refer to John Doe, MD for all chronic pain management and medicaon refills.

Date: 9/15/2015 Plan of Care Approval:

Figure 1. Sample plan of care.

been previously studied or published. We thus chose to include only those patients who had been in our case management program for a period of 6 or more years, a time period that we felt would provide insight into the longterm effects of case management on ED usage. All patients in the case management program meeting that criteria were enrolled in our analysis. Six years was chosen as the minimum time in case management for enrollment in our study as, based on the numbers of patients in the program and their duration of time in the program, it was felt to be a sufficient amount of time to provide us with a long period of time to analyze, while still maintaining a large sample size.

Our research group has performed previous analysis on this program, evaluating the efficacy of the program in reducing ED visits in the short term (22). Our previous analysis also evaluated the effect of the program on reducing ED computed tomography usage, as well as the efficacy of the program in getting patients needed services. Our focus in this analysis was whether or not the effects of case management in reducing ED visits persist over time and to explore the care plan changes involved in patients needing a revision of their initial POC. As such, we did not repeat any additional analyses or evaluations of the efficacy of the program beyond the number of visits per patient per year.

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Using the hospital’s electronic medical record system, Sunrise Clinical Manager (version 14.3; Allscripts Healthcare Solutions, Chicago, IL), all ED visits by all patients meeting inclusion criteria were reviewed from 1 year prior to enrollment in the program through December 2014. For each patient, baseline demographic information was recorded, including insurance status and whether or not the patient had a primary care doctor at the time of enrollment in the program. Each patient’s case management POC was also reviewed, and each aspect of the POC (such as primary care referral, psychiatric referral, or restricting refills of chronic pain medication) was recorded. For each revision of the POC, the number of visits 1 year prior to and after the revision was recorded, as were any changes made to the patient’s plan. Data were abstracted from the medical record by a single reviewer into a standardized form using Microsoft Excel (Excel 2013; Microsoft Corporation, Redmond, WA). The primary outcome measure for the study was the number of ED visits per patient per year, with the hypothesis that case management would decrease the number of ED visits. Subsequent to this, we also measured the frequency with which patients required a revision to the POC, the number of visits in the year prior to and after any revisions to the POC, the initial aspects of patient plans, and any changes made to patient plans during revisions of the POC. Unfortunately, as of the time the study was performed, our hospital did not have any system in place to share information with other institutions, and our data thus reflect ED usage at our institution only. Once all data from all ED visits from patients in the program during the period of study were collected and imported into a spreadsheet, we proceeded with data analysis. For our primary outcome measure, we calculated the number of visits per year for each patient in the year prior to enrollment in the program, as well as the number of visits per year in each of the subsequent years after enrollment. To evaluate for statistical significance, we then used an unpaired, two-tailed, Student’s t-test to compare the number of visits in the year prior to enrollment to the number of visits in each of the years after enrollment. Given the possibility of type I error with the multiple t-tests used to compare the number of visits per year in the year prior to enrollment to each of the years after enrollment, repeated measures analysis of variance (ANOVA) testing was performed to confirm statistical significance. In reviewing the revisions to the original POC, we recorded all instances in which patients required an initial revision to the POC. We recorded all visits in the year prior to and after revision, and used an unpaired, twotailed, Student’s t-test to compare the number of visits in the year prior to initial revision to the number of visits in the year after initial revision. A small group of patients

C. A. Grover et al.

were identified who required a second revision to their POC. This analysis was repeated for all instances of a second revision. In regards to the various aspects of each patient’s case management plan, we recorded all aspects of the plan from the patient’s initial enrollment in the program. We then recorded all changes made as a part of any subsequent revisions. RESULTS As of the time of data collection and analysis, a total of 533 patients were enrolled in the case management program. This number of 533 includes patients who have been in the program for as little as one month all the way up to eight years. There were 199 patients who met our inclusion criteria of being enrolled for 6 or more years and were included in our analysis. Of this group, 199 patients had been enrolled for 6 or more years, 126 had been enrolled for 7 or more years, and 73 had been enrolled for 8 or more years. Demographic information on the study subjects at the time of enrollment in the program can be found in Table 1. The average age of all patients enrolled in our analysis was 42.6 years at the time of enrollment, with the youngest patient being 19 at the time of enrollment, and the oldest patient being 79 at the time of enrollment. Women accounted for 67.8% of patients in our study group. In the year prior to enrollment, the patients in our study population made a total of 3184 visits, which represents an average of 16.0 visits per person per year. As Table 1. Baseline Demographic Information of Study Subjects (n = 199)

Homeless Male Female Has primary care physician No primary care physician Insurance type HMO Work comp Medicare Medicaid Commercial Hospital-sponsored care Military None Ethnicity White Black Asian Other Latino

Number of Patients

Percent of Total

9 64 135 175 24

4.5 32.2 67.8 87.9 12.1

1 7 49 52 37 6 11 36

0.5 3.5 24.6 26.1 18.6 3.0 5.5 18.1

144 31 1 8 15

72.4 15.6 0.5 4.0 7.5

HMO = health maintenance organization.

The Efficacy of Case Management on ED Frequent Users

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Table 2. Visits per Patient per Year Prior to Enrollment and after Enrollment

Year prior to enrollment Year 1 after enrollment Year 2 after enrollment Year 3 after enrollment Year 4 after enrollment Year 5 after enrollment Year 6 after enrollment Year 7 after enrollment Year 8 after enrollment

Number of Patients

Total Visits

Visits per Person per Year

p Value

199 199 199 199 197 194 192 126 73

3184 1420 807 608 646 605 379 261 136

16.0 7.1 4.1 3.1 3.3 3.1 2.0 2.1 1.9

<0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001

demonstrated in Table 2, the number of visits made by this group of patients declined significantly after enrollment in the program, with a persistent effect throughout all years after enrollment. Of note, 8 patients died during the period we reviewed, accounting for the change in number of patients beginning in year 4. The number of visits per year after enrollment as compared to the year prior to enrollment was found to be statistically significant for all years after enrollment based on analysis with the Student’s t-test. Repeated-measures ANOVA testing confirmed statistical significance, with a p value of < 0.001. A total of 29 patients (14.6% of total study population) required an initial revision to their initial care plan. This revision occurred, on average, 2.8 years after the initial case management plan was implemented. In the year prior to the revision, these patients made 648 ED visits, or 22.3 visits per patient per year. In the year after revision, these patients made 282 ED visits, or 9.7 visits per patient per year. This was found to be statistically significant, with a p value of 0.001. A total of 5 patients (2.5% of total study population) required a second revision to their initial care plan and first revision. This revision occurred, on average, 2.6 years after the initial case management plan was implemented. In the year prior to the revision, these patients made 176 ED visits, or 35.2 visits per patient per year. In the year after revision, these patients made 65 visits, or 13.0 visits per patient per year. This was not found to be statistically significant, with a p value of 0.19. In reviewing the various aspects of the care plans for the patients in our group, the vast majority of patients seemed to be recurrently using the ED for chronic pain and misuse of prescription medications. Care plans included restricting the prescription at the time of discharge of prescription opiates, benzodiazepines, and muscle relaxants for chronic conditions in the ED in 82.9% of patients enrolled in the program. Furthermore, the use of such medications for chronic conditions while in the ED was restricted in 71.4% of patients. Additionally, 30.7% of patients were referred for chemical dependency evaluation/drug abuse treatment, whereas 25.6% of

patients were referred to pain management. A complete list of the frequency of the various aspects of care plans is presented in Table 3. For those patients requiring an initial revision of their POC, the most common aspects of the POC were to restrict the use of opiates, benzodiazepines, and muscle relaxants for chronic conditions in the ED as well as at discharge. In the majority of these cases, this involved having to reinforce the initial POC as providers had deviated away from the initial plan. Patients were also frequently referred to support groups and physical therapy in this group, which was predominantly a new aspect to the POC. A complete list of the frequency of the various aspects of initial revision of care plans is presented in Table 4. For those patients requiring a second revision of their POC, the most common aspects of the POC were to restrict the use of opiates, benzodiazepines, and muscle relaxants for chronic conditions in the ED as well as at discharge. In all cases this involved reinforcing the initial Table 3. Frequency of Various Aspects of Initial Care Plans (n = 199) Number of Percent of Patients Patients Restricted discharge meds for chronic conditions Restricted meds in ED for chronic conditions Referral to chemical dependency/drug treatment Referral to Pain Management Referral to support group Referral to Social Services Referral to a primary care physician Referral to Psychiatry Referral to Physical Therapy Referral to homeless medical clinic Referral to Alcoholics Anonymous Assistance in obtaining insurance Referral to Neurology Assistance with smoking cessation Referral to Dentistry Referral to Occupational Therapy ED = emergency department.

165

82.9

142

71.4

61

30.7

51 29 27 18 12 7 7 4 2 2 2 2 1

25.6 14.6 13.6 9.0 6.0 3.5 3.5 2.0 1.0 1.0 1.0 1.0 0.5

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Table 4. Frequency of Various Aspects of Care Plan Revisions Number of Patients

Percent of Patients

Cases of New Addition to POC

Percent of Revisions

Cases of Reinforcement of POC

Percent of Revisions

23

79.3

9

39.1

14

60.9

19

65.5

5

26.3

14

73.7

11 5 3

37.9 17.2 10.3

8 5 1

72.7 100.0 33.3

3 0 2

27.3 0.0 66.7

3 3 2 1 1

10.3 10.3 6.9 3.4 3.4

2 3 1 1 0

66.7 100.0 50.0 100.0 0.0

1 0 1 0 1

33.3 0.0 50.0 0.0 100.0

5

100.0

0

0.0

5

100.0

3

60.0

0

0.0

3

100.0

3 2 1

60.0 40.0 20.0

1 1 1

33.3 50.0 100.0

2 1 0

66.7 50.0 0.0

1

20.0

1

100

0

0

Revision 1 (n = 29) Restricted meds in ED for chronic conditions Restricted discharge meds for chronic conditions Referral to support group Referral to Physical Therapy Referral to chemical dependency/drug treatment Referral to pain management Referral to social services Referral to a primary care physician Referral to Alcoholics Anonymous Referral to Psychiatry Revision 2 (n = 5) Restricted meds in ED for chronic conditions Restricted discharge meds for chronic conditions Referral to support group Referral to Physical Therapy Referral to chemical dependency/drug treatment Referral to Psychiatry POC = plan of care; ED = emergency department.

C. A. Grover et al.

The Efficacy of Case Management on ED Frequent Users

plan as providers had again deviated away from the initial plan. A complete list of the frequency of the various aspects of the second revision of care plans is presented in Table 4. DISCUSSION In looking at the primary outcome measure, the number of visits per patient per year prior to and after ED case management, our case management program has reduced ED visits, with an effect that is persistent over time. In the first year after enrollment, the frequent users in our program dropped the number of visits per patient per year by more than 50%, but interestingly still made approximately seven visits per year, which still qualifies as frequent ED use based on the original definition of four or more visits per patient per year (23–25). In the second year after enrollment, the number of visits per patient per year had decreased by 75% from preenrollment levels, but the group was still averaging four visits per patient per year, which again still qualified for frequent use. It was not until the third year after enrollment that the group averaged fewer than four visits per patient per year, and could no longer be considered frequent users. This effect persisted out through the eighth year after enrollment, namely, that the patients in our study group no longer met criteria for frequent use in and after the third year after enrollment in our case management program. There are several possibilities as to the reason why ED usage dropped as it did in our study. The first is that our case management program was effective in reducing ED visits by helping patients to get appropriate treatment for their underlying medical issue causing frequent ED use. For example, patients with chronic pain that were better managed by their primary care provider or a pain medicine physician would no longer need to come to the ED for refills of pain medication. This would seem to be consistent with the fact that ED use decreased to normal levels over a matter of approximately 2 years, as conditions such as chronic pain or substance abuse may take time to treat appropriately. Another possibility, as mentioned in the Limitations section, is that patients were simply going to other hospitals to seek care after being placed in case management at our institution. This would seem unlikely, as the patients in our program still qualified as frequent users in the first 2 years after enrollment in the program, despite their overall use having decreased. Additionally, given the very high prevalence of restriction of opiates, benzodiazepines, and muscle relaxants for chronic conditions in the care plans for our patients, there would be little reason for them to return to our ED if they had not made any improvements and were simply coming to the ED to obtain these medica-

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tions. This would suggest that ED visits subsequent to enrollment in the program were for more acute problems or injuries, and that patients were not just going to other hospitals. However, as we do not have data on usage at other hospitals, this is not definitively known. In reviewing the patients that required a revision to the original POC, this group of 29 patients demonstrated highly frequent ED use (22.3 visits per patient per year) in the year prior to their revision despite their enrollment in case management. A revision, however, was found to be a successful means of reducing ED usage, but this group of patients still continued to demonstrate frequent ED use in the year after the revision (9.7 visits per patient per year) despite the change to the POC. In these patients, we noted several trends in the revisions to the POC that help to better understand this group. Nearly 80% of patients required a POC restricting the use of opiates, benzodiazepines, and muscle relaxants in the ED for chronic conditions, and two-thirds required similar restrictions of these medications for discharge for chronic conditions. This suggests that this group of patients were continuing to have issues with prescription medication misuse and chronic pain despite our efforts in enrolling them in case management. Furthermore, in the majority of cases, the revision to the POC was simply to reinforce the original POC to restrict the use of these medications, suggesting that our providers had stopped after the POC, which had resulted in increased ED usage. This would suggest that our case management program is effective in reducing ED visits, but loses efficacy obviously once the POC is ignored by providers. We also provided a significant number of referrals to physical therapy and support groups in this group of patients at the time of revision, most of which were new to the POC. This suggests that an initial approach to a care plan for a patient with frequent ED visits may be more successful initially if multiple specialties and services are involved in a more comprehensive approach to the patient. In looking at the patients requiring a second revision to the POC, this seems to be a very difficult group of patients to manage. Despite initial case management care plans and revisions to the POC to try to reduce use, these 5 patients were averaging 35.2 visits per patient per year prior to the second revision. A second revision did seem to reduce use (though not statistically significant due to the small number of patients), but even despite a second revision, these patients continued to use the ED heavily, averaging 13.0 visits per patient per year after the second revision. As seen with the patients requiring an initial revision, restriction of opiates, benzodiazepines, and muscle relaxants in the ED and at discharge for chronic conditions were very frequently a part of the POC for the second revision. Interestingly, in all of these cases, the revision involved reinforcing restriction of such

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medications. Furthermore, review of the visits demonstrated a pattern of the patient presenting relatively infrequently to the ED when the care plan was being followed. For unclear reasons, for these patients, each of them had a visit in which the care plan was not followed, and the patient was given a prescription for an opiate, benzodiazepine, or muscle relaxant for their chronic illnesses. After such visits, ED usage increased drastically, and care providers continued to violate the POC on the basis that it had been violated previously. These cases, though small in number, suggest again that the recurrence of excessive ED use may come from our providers not following the care plan. This also highlights the challenge of treating addiction and chronic pain in this group. We also, in this group, provided referrals to support groups and physical therapy, again highlighting the need for multi-modal approaches to these challenging patients. One potential criticism of our program is that the majority of care plans, both initially and in revision, involved restricting the use of potentially abused or misused medications in the ED and at discharge for chronic conditions. We, furthermore, had a relatively low rate of referrals to other specialties such as physical therapy and social services. One reason for this comes from the fact that at the time a person was enrolled into our case management program, we contacted their primary care provider to alert them of the need for and specifics of a POC in our ED case management program. Most of the primary care providers of our patients were unaware of the frequent ED use and problems with medication misuse and untreated symptoms. Upon hearing of the patient’s need for case management, a large number of the primary care providers we contacted requested that they would take over the patient’s pain management and arrange for further treatments and referrals. Most likely, therefore, more patients in our program ultimately received referrals to other specialties and services, but these referrals were not recorded in our analysis. Additionally, a high number of primary care doctors were willing to take over management of chronic pain, obviating the need for a referral to pain management in their POC. Finally, there may have been some bias in the selection of which patients required a revision to the POC. A few patients were unhappy with their POC, and contacted the administration to request a revision to their POC or to be removed from the program. Anecdotally, the majority of these self-referrals for revision involved patients that were displeased with the restriction of opiates, benzodiazepines, and muscle relaxants for chronic conditions. This likely, in part, accounts for the frequent need to reinforce the restriction of such medications in the revisions to the care plans. Furthermore, there was no standardized reason to consider a patient for a revision. In some cases, it was because their use had increased to

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the point that they were meeting the criteria for initial enrollment in the program based on their ED use. In other cases, as mentioned, it was by patient self-referral. This may have biased patient selection for revision, and should be considered when reviewing the data on our patients requiring changes to their original POC. Limitations Limitations to our study should be acknowledged. First, this study was conducted at a single institution, which may limit the generalizability of our data to other institutions with different demographics. Furthermore, we had an extremely high proportion of patients in our case management program for prescription drug abuse or chronic pain and a low proportion of patients who were homeless or with chronic medical problems such as diabetes or congestive heart failure. This also, as many previous studies of ED case management have been on homeless patients or patients with chronic complex medical problems, may limit the generalizability of our data. Our study design was a retrospective chart review. Although there is likely to be little bias as the data recorded involved almost no interpretation on the part of the chart reviewer, a prospective analysis would be considered to be more accurate. Similarly, without randomization, it is difficult to exclude regression towards the mean as contributing to the success of our program in reducing ED usage. Finally, though the overall trend of our study would demonstrate that case management to reduce ED visits in frequent users is effective at our hospital, we do not have any data on ED use at other institutions or clinics to determine whether or not overall ED use was decreased. It is possible that our patients, after being in case management, simply chose to seek care at other institutions or moved out of the area. Our institution, at the time of analysis, did not have access to records from any other institutions. As our hospital works to share information securely with other hospitals in the future, better analysis of how our program affected ED visits at other hospitals may be obtained. With increasing emphasis on cost of care and use of resources in health care in the United States, the cost of the program and financial implications of the program are important. Our group has collected financial data on the patients in the program, with the plans to perform a cost analysis of the program and publish it in a future manuscript. CONCLUSIONS Although case management has been studied in the short term, and has been shown to be an effective way to reduce ED visits in patients with patterns of frequent use of the ED, this study demonstrates that case management of ED frequent users seems to remain effective over time.

The Efficacy of Case Management on ED Frequent Users

However, certain patients may continue to demonstrate frequent use despite case management, and may require revisions of their POC to curb excessive use. Such patients seem to most commonly have underlying prescription medication abuse or chronic pain issues. REFERENCES 1. Martin GB, Stokes-Buzzelli SA, Peltzer-Jones JM, et al. Ten years of frequent users in an urban emergency department. West J Emerg Med 2013;14:243–6. 2. Ruger JP, Richter CJ, Spitznagel EL, et al. Analysis of costs, length of stay, and utilization of emergency department services by frequent users: implications for health policy. Acad Emerg Med 2004;11:1311–7. 3. Doupe MB, Palatnick W, Day S, et al. Frequent users of emergency departments: developing standard definititions and defining prominent risk factors. Ann Emerg Med 2012;60:24–32. 4. LaCalle E, Rabin E. Frequent users of emergency departments: the myths, the data, and the policy implications. Ann Emerg Med 2010; 56:42–8. 5. Murphy SM, Neven D. Cost effective: emergency department care coordination with a regional hospital information system. J Emerg Med 2014;47:223–31. 6. Liu SW, Nagurney JT, Chang Y, et al. Frequent ED users: are most visits for mental health, alcohol, and drug-related complaints? Am J Emerg Med 2013;31:1512–5. 7. Vinton DT, Capp R, Rooks SP, et al. Frequent users of US emergency departments: characteristics and opportunities for intervention. Emerg Med J 2014; http://dx.doi.org/10.1136/emermed2013-202407. Epub ahead of print. 8. LaCalle EJ, Rabin EJ, Genes NG. High-frequency users of emergency department care. J Emerg Med 2013;44:1167–73. 9. Miller JB, Brauer E, Rao H, et al. The most frequent ED patients carry insurance and a significant burden of disease. Am J Emerg Med 2013;31:16–9. 10. Konstantopoulos WL, Dreifuss JA, McDermott KA, et al. Identifying patients with problematic drug use in the emergency department: results of a multisite study. Ann Emerg Med 2014;64:516–25. 11. Ondler C, Hegde GG, Carlson JN. Resource utilization and health care charges associated with the most frequent ED users. Am J Emerg Med 2014;32:1215–9.

9 12. Weiss A, Schechter M, Chang G. Case management for frequent emergency department users. Psychiatr Serv 2013;64:715–6. 13. Castillo EM, Brennan JJ, Killeen JP, et al. Identifying frequent users of emergency department resources. J Emerg Med 2014;47: 343–7. 14. Scott J, Strickland AP, Warner K, Dawson P. Frequent callers to and users of emergency medical systems: a systematic review. Emerg Med J 2014;31:684–91. 15. Shapiro JS, Johnson SA, Angiollilo J, et al. Health information exchange improves identification of frequent emergency department users. Health Aff (Millwood) 2013;32:2193–8. 16. McCormack RP, Hoffman LF, Wall LF, et al. Resource-limited, collaborative pilot intervention for chronically homeless, alcoholdependence frequent emergency department users. Am J Public Health 2013;103(Suppl 2):S221–4. 17. Fertel BS, Hart KW, Lindsell CJ, et al. Patients who use multiple EDs: quantifying the degree of overlap between ED populations. West J Emerg Med 2015;16:229–33. 18. Crane S, Collins L, Hall J, et al. Reducing utilization by uninsured frequent users of the emergency department: combining case management and drop-in group medical appointments. J Am Board Fam Med 2012;25:184–91. 19. Kumar GS, Klein R. Effectiveness of case management strategies in reducing emergency department visits in frequent user patient populations: a systematic review. J Emerg Med 2013;44:717–29. 20. Pines JM, Asplin BR, Kaji AH, et al. Frequent users of emergency department services: gaps in knowledge and a proposed research agenda. Acad Emerg Med 2011;18:e64–9. 21. Tricco AC, Antony J, Ivers NM, et al. Effectiveness of quality improvement strategies for coordination of care to reduce use of health care services: a systematic review and meta-analysis. CMAJ 2014;186:E568–78. 22. Grover CA, Close RJ, Villarreal K, et al. Emergency department frequent user: pilot study of intensive case management to reduce visits and computed tomography. West J Emerg Med 2010;11: 336–43. 23. Hunt KA, Weber EJ, Showstack JA, et al. Characteristics of frequent users of Emergency Departments. Ann Emerg Med 2006;48:1–8. 24. Byrne M, Murphy AW, Plunkett PK, et al. Frequent attenders to an Emergency Department: A study of primary health use, medical profile, and psychosocial characteristics. Ann Emerg Med 2003; 41:309–18. 25. Locker TE, Baston S, Mason SM, et al. Defining frequent use of an urban Emergency Department. Emerg Med J 2007;24:398–401.

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ARTICLE SUMMARY 1. Why is this topic important? Frequent users of the Emergency Department (ED) represent a group of patients commonly seen in the ED, and account for a large percentage of both ED visits and use of clinical resources. 2. What does this study attempt to show? Case management has been previously shown to reduce ED visits in frequent users in the short term in multiple studies. The authors sought to determine whether or not case management to reduce frequent ED usage would be effective in the long term. 3. What are the key findings? In this study, case management in frequent users of the ED demonstrated a significant reduction in ED usage, an effect that persisted from the year after enrollment out to 8 years after enrollment. A small group of patients demonstrated recurrence in ED frequent use despite case management, and had to have a revision to their care plan in the program. This most commonly involved patients with underlying prescription drug misuse and chronic pain. 4. How is patient care impacted? Case management seems to be an effective strategy in both the long and short term to reduce ED visits in frequent users of the ED. Some patients, most commonly those with chronic pain and prescription drug abuse, may continue to demonstrate frequent use and may require revisions to their plan of care to curb ED usage.