Dear Director: Our RNs roll their eyes when they see certain chronic pain patients on the tracker. They say that the MDs are all over the map as far as how we treat these patients, with many giving opioids – including some of our senior docs – and that something needs to be done. It frustrates me that my colleagues repeatedly prescribe opioids in the ED to patients with chronic pain, but is it really my job to police how my practice partners are treating patients?
ED “frequent flyers” have likely been around for as long as there have been EDs. Literature started appearing on this subject over the last 10 years and although there have been articles in the lay press for 10 years, the article in the New Yorker by Dr. Atul Gawande in 2011 on the “super utilizers” may have been the spark that recharged the conversation. One effective tool in managing these high utilizers has been the development of care plans. Key to the success of care plans is having everyone on the team buy-in to the concept and follow the game plan. These rules should apply to your chairman and other senior docs as well.
Frequent users have been found to comprise approximately 5% of all ED patients. However, given their frequent use of the ED, these patients may account for up to 25% of all ED visits. Although the definition of a frequent user may be someone who comes to the ED four or more times in a year, very frequent users have been defined variably as those patients that visit the ED more than 10-20 times over the course of a year. I remember a patient that used to come in 10 times a week, usually by EMS. Overall, these patients tend to have lower acuity complaints and are less likely to be admitted than patients with fewer visits per year. They are also less likely to be over the age of 65 but more likely to have substance abuse issues.
There are several reasons why we should try to fix the problem of frequent users. First, we can improve the quality of care provided to these patients. The care currently provided to frequent users is inconsistent between visits and typically does not address the root cause — which may include substance abuse, mental illness, absence of primary care, etc. Second, these patients consume a disproportionate amount of health care resources. We have an ethical obligation to address the cost issues now; although as reimbursement models evolve, emergency physicians (and the hospital) will likely be financially incentivized to provide more cost efficient care to these patients. Third, developing a coherent response to the frequent user issue will improve the morale of the emergency providers. No one enjoys practicing in a system that supplies ineffective and inconsistent care – especially when it results in the repeated prescription of controlled substances.
Hospitals have tried to combat this in many ways. The most common attempt has been the “case management” approach. In this model, a multi-disciplinary team composed of physicians, nurses, social workers, and case managers reviews a patient’s care and determines what resources (mental health, substance abuse, pain management, primary care coordination) are needed. A “care plan” is created for the benefit of the providers in the ED that allows more consistent and informed care between visits. This case management approach has been found to be successful in most studies. Success was defined as a decrease in ED visits by these patients and/or an improvement in patient social or clinical outcomes.
Naming this committee is key. I’ve had several conversations with patients who called me after they received a letter regarding their care plan and it’s much nicer to tell a patient their care was reviewed by the care plan committee that is a multidisciplinary committee created to optimize a patient’s care than if they were reviewed by the frequent flyer committee. Also, although perhaps appropriately named, something like the Super User Committee will confuse everyone who has anything to do with IT or the people who are the super users for your EMR or any other computerized process taking place.
Strategies to Address Frequent Users
Chronic pain patients typically comprise about 20-40% of the frequent user population. In the wake of dilaudid free ERs, CDC guidelines and even the President talking about opioid abuse, care plans, addressing these chronic pain patients becomes even more critical. Guidelines for these patients are typically developed by emergency physicians and pain management specialists and these guidelines make up the cornerstone of effectively reducing utilization by frequent users. There are some fairly simple ways to start, such as avoiding the use of long acting oral opioids and all injectable opioids. Prescribe only limited amounts of any opioid, review any prescription monitoring program that is available to you before prescribing opioids (at least in certain patient situations), and do not refill lost or stolen prescriptions. If a patient has a primary care physician or a pain management physician, those docs should be consulted before prescribing opioids for chronic pain.
Care plans should be individualized to the patient’s needs, developed in combination with the patient’s PMD or specialist (neurologist for frequent, severe migraines for instance), reviewed and agreed upon by the committee and then ultimately drafted by the committee chair (or their designee). These plans can include the recommendation to limit or withhold opioid medications. Once developed, the care plan needs to be communicated to the patient, typically via certified mail or hand delivered at the time of the next ED visit (with appropriate documentation in the chart that the patient received the care plan). It’s critically important for the docs to have awareness that a care plan exists for a patient. One of the best solutions is for the ED tracker to alert the provider. It is also important that the care plan is stored in a HIPPA compliant manner – ideally within the EMR and not in a binder at the charge RN desk.
Other stakeholders in the healthcare system may have a financial or mission oriented incentive to help with these patients as well. Potential partners include EMS, insurers such as Medicaid, the local mental health agency and the local homeless advocates. Within the hospital, one of the most effective partnerships may be with case management. Many frequent users have a complicated medical illness, mental illness, or substance abuse and benefit greatly from care coordination provided by a case manager. Partnering with these agencies can prove very effective in managing certain frequent users.
One of the key aspects of this committee, after the creation of the care plans, is to understand how successful the committee is. This can be accomplished several ways, including measuring the reduction of ED visits by frequent users who have been referred to case management as well as tracking the number of visits by all ED frequent or super users monthly and establishing monthly visit targets. While the ultimate outcome measure of the committee is re-direct patient so that they receive their care in more appropriate settings, it is equally important is to know whether the care plans are being followed. This starts with audits. Depending on the number of patients you have with care plans, it may not be feasible to audit every patient every time they come to the ED, but it’s certainly reasonable to audit your top 10-20 highest utilizers on a monthly basis. The audit questions can include whether the care plan was referenced in the medical decision making note, was the care plan followed (and if not, was a comment made to explain the deviation from the plan).
I can remember a meeting I attended where a hospitalist said that without the proper incentive, or consequence, it would be unlikely we would see changes from their group. That stuck me as likely to be true, but also probably more honesty than you should give in a multispecialty hospital meeting. I’ve written about it before, but I think everyone needs a reminder of Simon Sinek’s leadership philosophy on the importance of starting with “the why.” Standardizing care for some of these difficult patients is important for their quality of care and it’s important for the morale of our staff. We owe it to each other to follow the plan, rather than take the easy road out and paint our colleagues as the bad guy the next time the patient comes. Once you’ve established the why, then you need to show the data. This links back to the hospitalist’s comments that if you’re not going to incentive someone, there needs to be consequences. I’m a big believer in having transparent data and I consider showing the audit results for any quality assurance project a must. I think the negative consequence is the peer pressure of not performing at the desired expectation.
Now is the time to step forward and be involved with this committee. Audit the charts. Show the data. While the committee chair needs to be the one to meet with any outlier, i.e. someone not consistently following the care plans, to explain the why, show the data, and obtain the buy in, this committee needs involvement from the docs who are on the front lines seeing these patients on a regular basis.
Benefits of addressing ED frequent users (especially those with chronic pain) include improved quality of care, increased staff morale, and decreased hospital costs. Hospitals have recently identified frequent user interventions as a high value activity, partly due to anticipated changes in payment models. Strategies for addressing ED frequent users include developing chronic pain guidelines, care plans, partnering with other healthcare stakeholders, and applying case management resources. Creating the care plans is important although you should also expect to invest some time tracking the impact they have on patients visits and the compliance of your providers with the plans and then providing them with the appropriate feedback.