Overview

Implementation of the Discharge to Medical Home model, a new care delivery model that routes non-urgent ambulatory emergency department (ED) patients to a nearby primary care clinic to establish care within a medical home.

In collaboration with Healthcare: The Journal of Delivery Science and Innovation

Organization Name

Carolinas HealthCare System Anson, Carolinas Primary Care

Organization Type

• Community health system
• Community hospital
• Rural health system

Local/Organizational Context

• Carolinas HealthCare System Anson is a rural, community-focused hospital and primary care clinic that serves as the largest provider of healthcare in Anson County, North Carolina.
• Its mission is to “improve the health of Anson County,” and accordingly, aims to decrease avoidable ED visits and increase access to primary care among Anson county residents.
• Carolinas HealthCare System Anson is part of Atrium Health, a large, vertically-integrated healthcare system with facilities in North and South Carolina.
• Anson County has been considered one of the unhealthiest communities in North Carolina. In addition to nearly ¼ of the population living in poverty, much of the community was lacking access to high quality healthcare.
• Anson Community Hospital was facing financial difficulties. Patients were visiting the ED to receive care outside of normal business hours due to lack of urgent care clinics or retail-based care options, leading to ED overcrowding and increased healthcare costs.
• In 2012, Anson Community Hospital was converted into Carolinas HealthCare System Anson, a 24-hour ED and attached primary care facility, allowing ED patients with non-urgent or minor medical issues to be transferred and treated by a primary care physician.

Patient Population Served and Payor Information

• Carolinas HealthCare System Anson serves emergency department patients in Anson County, a rural county in southeast North Carolina.
• Anson County consists of about 48% African American residents and 46% Caucasian residents. Nearly 25% of residents live below the poverty line.

Leadership

• The program was designed by a multidisciplinary project team under the leadership of Mike Lutes, President of the Southeast Division of Atrium Health (formerly Carolinas HealthCare System)
• The program was evaluated by Kathryn Zager and Yhenneko J. Taylor.

Funding

• This program has not received grant funding.

Research + Planning

• Infrastructure changes: a new facility opened in July 2014 and contains a primary care clinic, pharmacy, imaging center, emergency department, surgery suite, community space, and a 15-bed inpatient unit.
• Establishment of primary care clinic operations similar to a patient-centered medical home (PCMH).

Tools or Products Developed

• Development of Discharge to Medical Home, a care model by which walk-in ED patients with non-urgent medical ailments can be scheduled for same-day care at an adjoining primary care facility. It has two main goals:
  • Providing patients with healthcare in the appropriate setting
  • Connecting patients with primary care providers who can address their general health
• Development of a triage protocol by the Medical Director at the primary care clinic, which outlines complaints that the primary care clinic staff will not be comfortable treating: chest or abdominal pain, acute injuries, high blood pressure, abscess, or post-op issues.

Training

• ED Registration Registrars received training on the process for implementing the discharge to medical home discharge code that was used to indicate patients who were discharged from the emergency department after receiving the medical screening exam and scheduled for a same-day visit in the primary care clinic.

Tech Involved

• Electronic medical record

Team Members Involved

• ED Advanced Care Practitioner
• Primary Care Physicians
• Registration Registrar
• RNs

Workflow Steps

• Patients check in at a shared registration desk between the ED and primary care clinic.
• Patients with appointments are checked in and go directly to the primary care clinic waiting room.
• Patients without appointments are triaged by the registrar.
  • Registrar asks for chief complaint, screens patients using the Emergency Severity Index (ESI)
    • Patients with ESI levels 1 (life threatening) or 2 (high risk) are admitted directly to the ED.
    • Patients with ESI levels 3 (requires in depth evaluation), 4 (few resources needed), or 5 (no resources needed) receive a medical screening exam conducted by an ED registered nurse and an advanced care practitioner.
  • The medical screening exam lasts 3-7 minutes on average. The nurse collects vital signs while the advanced care practitioner listens to the patient describe their reason for visit. The screening is documented in the electronic medical record. The advanced care practitioner then decides on the appropriate location for visit.
  • Patients with non-urgent needs are discharged to the medical home and scheduled for a same day appointment at the primary care clinic.
  • Patients with urgent needs are admitted to the ED, and the nurse obtains additional information to complete standing orders.

Budget

• >$1M

Budget Details

$20 million for structural changes

• Structural changes: cost to convert 52-bed community hospital into facility containing primary care clinic, pharmacy, imaging center, ED, surgery suite, community space, and 15 inpatient beds.
• Operations and staff compensation: cost to extend the hours of the primary care clinic from closing at 5:00 p.m. to closing at 8:00 pm to better accommodate ED patient volumes.

Where We Are

• The program was implemented in July 2014 and is ongoing.

Outcomes

• Number of ED visits:
  • In one year following the intervention, the number of ED visits declined by 5% from 14,753 to 14,017 visits.
• Percent of ED visits occurring during hours when the “Discharge to Medical Home” intervention was operating:
  • The intervention reached 38% of all ED visits in the year after implementation and 90% of all daytime ED visits (5385/5996).
• Percent of visits discharged to the primary care clinic:
  • In the first year after implementation, 36% of patients who presented to the emergency department as walk-ins were discharged to the medical home.
  • 2201 potential emergency department visits were avoided.
• Readmissions to the ED:
  • Patients discharged to medical home had lower rates of readmission than patients who were sent home after being seen in the ED.
  • The odds of a return visit to the ED within 7, 14, and 30 days were 27-30% lower for patients discharged to medical home compared to those discharged to home care, when adjusting for age and ESI.
• Time spent in the ED:
  • Patients discharged to medical home spent less time in the ED.
  • Among patients with an acuity level of 4 (less urgent), the average time spent in the ED from arrival through medical screening exam decreased from 135 minutes to 33 minutes for patients admitted to the ED versus those discharged to primary care (p<0.001).
  • Among patients with an acuity level of 5 (non-urgent), the difference in time spent in the ED was 66 minutes (p<0.001).
• Top diagnoses for ED visits:
  • Following the intervention, more serious conditions such as injuries, chest pain, and abdominal pain remained the top diagnoses.
  • There was a decline in more minor conditions such as upper respiratory infection, teeth diagnoses, and connective tissue diagnoses.

Benefits

• The Discharge to Medical Home model resulted in a 5% decline in ED visits and 2201 potential emergency department visits avoided, providing more appropriate and cost-efficient care.
• This intervention allows for an opportunity for patient education regarding the appropriate utilization of primary care versus ED. During the screening, the nurse explains to the patient why they are being discharged to the primary care clinic, and that they can continue to return there for regular healthcare visits.

Unique Challenges

• The primary care clinic did not operate 24 hours a day, 7 days a week like the ED. The primary care clinic hours were extended from 8:00 am to 5:00 pm until 8:00 pm, with the Discharge to Medical Home process in effect until 7:00 pm.
• Working to optimize scheduling needs for both established and walk-in patients was a challenge. Closure of several private primary care practices in the area led to an increased burden on the primary care clinic and Carolinas HealthCare System Anson as a safety net hospital. In order to balance needs of both types of patients, 13% of primary care visits were held for Discharge to Medical Home patients. Operational data such as appointment utilization, and patient volume by time/day were used to adjust the schedule.

Personnel Challenges

• In order to optimize staffing, the management team decided that having the charge nurse do the medical screening was the best solution because that role is already responsible for ED admissions & staff assignments.

Glossary

Figure 1: Diagram of patient flow through Discharge to Medical Home model (as in Zager and Taylor paper)

Sources

Zager K, Taylor YJ. Discharge to medical home: A new care delivery model to treat non-urgent cases in a rural emergency department. Healthc (Amst). 2018 Aug 21. pii: S2213-0764(17)30261-0. doi: 10.1016/j.hjdsi.2018.08.001.