A Disease Management Education Program to Reduce Emergency Department Visits Among Adult Patients With Chronic Conditions:

Introduction

The escalating rate of avoidable Emergency Department (ED) visits represents a significant challenge to the U.S. healthcare system. Health service providers must address this issue by targeting the causes (Greenwood-Ericksen & Kocher, 2019).ED services continue to experience avoidable despite advancements in medical technology and better healthcare delivery systems (Hargreaves et al., 2020). ED visits, sometimes avoidable, are situations in which people seek emergent care, which could be due to poorly managed and lack of timely interventions (Cho et al., 2023). Avoidable ED visits cause resource strain, exacerbate the ED crisis, and potentially compromise patients with true emergencies (Giannouchos et al., 2021). Although the proportion of admissions through the ED may differ across studies, national estimates suggest figures range from 13% to 27%, which is evidence of the magnitude of this problem (Kanzaria et al., 2019). In New York, however, health disparities seen in ED visits are particularly acute. Resolving avoidable ED visits depends on implementing a multifaceted approach comprising patient education, expanding primary care access, and switching to disaster and acute health management (Alnasser et al., 2023).By obtaining in-depth insight into the relevant factors causing avoidable ED visits and making efforts towards their targeted interventions, healthcare organizations can relieve the pressure on the ED and arrange the resources more efficiently, improving the overall healthcare delivery system. This paper aims to provide a comprehensive overview of avoidable ED visits, explicitly focusing on New York, and implement an education program on disease management in a family practice setting in NY to reduce avoidable ED visits.

Problem Description

The state of New York’s densely populated urban centers, coupled with disparities in healthcare access and socioeconomic factors, contribute to a higher likelihood of individuals resorting to ED visits for non-emergent conditions (Greenwood-Ericksen & Kocher, 2019). For example, a study in New York City showed that around 15% of ED visits were possibly avoidable, which puts tremendous pressure on the healthcare system (Hargreaves et al., 2020). Either non-urgent ED visits or visits that could have been provided in another setting chiefly pose a problem for the healthcare system (Jeffery et al., 2020). Per Jeffery et al. (2020), such cases emerge when patients go to the ED for care for conditions that doctors could have managed within a primary care facility. Evidence from national surveys revealed that the number of cases of this nature was between 13% and 27% (Kanzaria et al., 2019). In New York, with the state’s distinctive characteristics prominent with numerous healthcare challenges, the problem becomes all the more urgent. The ED problem is multilayered and may exist among population parameters and feedback in attitude and behavior (Giannouchos et al., 2021). Similarities to the social and economic aspects of the population, such as no medical insurance and limited access to primary care providers, result in people overburdening EDs with non-urgent demands (Kanzaria et al., 2019). Additionally, cultural practices and viewpoints towards medical care services, language gaps, and people’s health literacy determine their preference for EDs over primary care as a symbol of being ill and in need of care (Alnasser et al., 2023).

Additionally, lack of insurance coverage represents a substantial challenge to using timely walk-in medical clinics, which can lead patients to use the ED as a solution to their primary healthcare (Alnasser et al., 2023). With insurance, many patients can avoid their conditions becoming terrible, escalating cases where conditions could have been prevented with timely primary care attendance (Greenwood-Ericksen & Kocher, 2019). Inadequately following up on treatment prolongs the problem of avoidable ED visits by not treating the underlying health concerns and preventing exacerbations (Giannouchos et al., 2021). The costs related to ED overcrowding are high, including administrative and support costs and bed days. Direct costs are the financial expenditures linked with medical evaluations, labs, tests, treatments, and medications given in ER attendances. For instance, a study by Giannouchos et al. (2021) provided an average of the direct costs of an ED visit that ranges between $580 to $1354 for US citizens, depending on the complexity of care offered. Indirect costs are caused by a dragging-out of the patient’s wait time, which could be negative consequences of low patient satisfaction, delayed care, and poor outcomes.

Furthermore, ED overcrowding can also stress and strain hospital resources and cause extra costs, man-hours, and money needed for staffing. According to Jeffery et al. (2020 the annual financial loss for a hospital can reach as high as $5 million because of congestion-related inefficiencies. These financial worries heighten the need for implementing targeted programs, which are aimed at guarding against useless visits to emergency departments and, at the same time, ensuring proper resource distribution (to promote efficiency and effectiveness in emergency care delivery system).

The direct costs impact patients and healthcare systems, making a strong case for community interventions to address the underlying causes of avoidable ED arrivals and make healthcare delivery more efficient and effective (Hargreaves et al., 2020).

Local Problem

In New York City, the dependence on hospital EDs for primary care among the uninsured and low-income populations is a significant issue. As of 1998, to this day,nearly three-quarters of all ED visits were for conditions that were either nonemergent or treatable in a primary care setting (Greenwood-Ericksen & Kocher, 2019). Alarmingly, 7% of these visits were potentially avoidable, showing a timely and effective primary care provision failure. Despite efforts to enhance primary care capacity, ED usage has remained steady over the years, highlighting systemic problems. Moreover, neighborhood variances in ED use highlight disparities in access to primary care, particularly affecting fee-for-service Medicaid beneficiaries in low-income areas like Central Harlem and the South Bronx (Greenwood-Ericksen & Kocher, 2019). Addressing this issue requires comprehensive strategies to improve primary care availability, reduce wait times, and strengthen coordination between EDs and primary care providers.

Several key impasses are facing the community. In particular, the evidence gaps are identified in the data collection system and mechanism to measure the problem’s scope and identify more specific patterns and trends among the local population (Jeffery et al., 2020). Without complete data, the healthcare industry faces difficulties in appropriately designing measures and allocating resources. Besides, a host of issues around enhanced care coordination and communication among primary care providers and EDs to allow patients to be referred and followed up by the appropriate sources need to be addressed, too. Currently, fragmented healthcare delivery systems contribute to individuals falling through the gaps, leading to recurrent visits to EDs for avoidable conditions (Kanzaria et al., 2019). The interim deficiency that calls for meeting all these in the local clinic requires some effort to implement quality improvement mechanisms that focus on patient education, access to primary care, and care coordination strategies.

Available Knowledge

To address avoidable ED visits, it is crucial to comprehend the current landscape of available information regarding factors contributing to patterns of ED utilization. Such research about ED visits is already more than clear with its different components like the outpatient data, the patient demographics, and even the external ones like the impact of the COVID-19 pandemic. Giannouchos et al. (2021) emphasized that outpatient visits to the ED were also significantly decreased during the COVID-19 pandemic. Visits focusing on medically non-life-threatening disorders that could have been managed in another healthcare environment declined, particularly for non-urgent medical illnesses. Moreover, research by Smith et al. (2019) emphasizes the importance of patient education programs in reducing avoidable ED visits. Educating programs stimulate patients to be more competent in treating and managing their health conditions, to understand the early indicators of exacerbation, and to ensure timely care in primary care settings. Indeed, just as Jones, Wang et al. found out, the same cell in chronic diseases such as congestive heart failure, diabetes, and hypertension was effective in reducing ED visits. These interventions could include in-patients being given self-monitoring tools, educational materials on keeping medication schedules, and lifestyle changes.

In addition to patient education programs, integrating technology-based solutions into healthcare delivery has shown promise. Patel et al. (2020) study points out that platforms, health mobile applications, and virtual networks enable patients to acquire educational resources conveniently, access monitoring tools remotely, and interact virtually through different networks. This sustains better self-governance and treatment program adherence, which supports the growth of family practice activities throughout society. Furthermore, collaborative care models involving multidisciplinary healthcare teams have reduced healthcare utilization, including ED visits. Kazale et al. (2018) report that care coordination, communication, and patients’ equal rights to top doctors lead to improved health outcomes. The implementation of collaborative care approaches along with patient education programs raises the effectiveness of interventions. It addresses elaborate and private causes responsible for avoidable Emergency Department visas.

Rationale for Conducting This Project

Addressing the problem of avoidable ED visits is imperative for optimizing healthcare delivery, improving patient outcomes, and enhancing the overall efficiency of the healthcare system. By conducting the project, several key objectives can be achieved. First, patients with not-so-acute conditions should be considered for other less resource-demanding outpatient specialties, which will unburden ED resources, reducing wait times, improving patient experience, and improving non-emergency care access for those in need. Further, with primary healthcare, improved medical access, and proper looking for options for healthcare, the project can lower both financial obligations and expenses for patients and institutions providing healthcare services. Moreover, integrating research-based strategies using current knowledge and best practices as a starting point will lend credibility to the outcome. It can be used as a model for researching similar issues in other fields. The project can support the delivery of healthcare services by eliminating barriers, including inefficiencies, a lack of resources, and inconsistencies in service delivery, resulting in improved health standards among the residents who enjoy the services.

Problem focus

The ED visits caused by avoidable events are an incredibly intricate problem for a small family practice in New York City, which is confounded by systemic factors and patient behavior. Disconnected care, due to poor communication and coordination between healthcare providers and weak links forces the community to rely on the ED for non-urgent issues (Greene et al., 2019). Sometimes, patients avail care from various providers or healthcare settings without the due coordination framework, worsening the issue of avoidable ED visits. However, the fact that people do not have medical insurance coverage prevents them from obtaining primary care services in time. It necessitates seeking medical attention from the EDs as a backup, which is the main problem (Williams & Haffizulla, 2021). Without insurance coverage, many patients end up being forced to postpone seeing a doctor until their conditions have worsened, and the only option left is seeking emergency care, which could have been avoided if the interventions had been provided in primary care.

In addition, the lack of good follow-up care is also responsible for increased trips to the ED, as follow-up visits are crucial for the management of underlying health issues and the exacerbations of the disease. Patients who previously attended EDs but left without proper follow-up plans are at risk of returning for the same issues, which can result in a continuous cycle of ineffective usage of healthcare services. The financial consequences of ED avoidable visits can be substantial and are constituted by both the direct cost of ED care and indirect costs related to ED overcrowding and the compromised quality of care (Williams & Haffizulla, 2021). The cost implications are too heavy for both patients and the healthcare system. Thus, addressing the root causes of avoidable ED visits appears imperative, as a more efficient and effective healthcare delivery system should be developed.

Smart Goal

The SMART goal framework has been selected for the quality improvement project.

• Specific: Develop and implement a patient education program targeting adult patients with chronic conditions, specifically congestive heart failure (CHF), diabetes, and hypertension, in a family practice setting in New York.
• Measurable: Decrease the number of avoidable ED visits by 3% among adult patients with CHF, diabetes, and hypertension within four months of implementing the patient education program.
• Achievable: The goal is achievable by utilizing evidence-based patient education strategies, leveraging existing resources within the family practice setting, and fostering collaboration among healthcare providers and patients. Training healthcare staff on effective patient education techniques and disease management protocols supports the goal of reducing avoidable ED visits.
• Relevant: The goal directly addresses the problem of avoidable ED visits, which poses significant challenges to patients, the healthcare system, and the practice regarding clinical metrics and reimbursement. Involving the patients in the decision-making process, educating them, and providing them with the necessary tools to manage chronic diseases will result in fewer unnecessary visits to the ED, better patient care, and more optimal usage of healthcare resources.
• Time-bound: The goal will be reached four months after patient education is implemented, which will involve an evaluation and readjustment if needed to ensure the highest efficiency.

Project Question

Among adult patients with chronic conditions (CHF, diabetes, and hypertension) in a family practice setting in New York, how does implementing a patient education program targeting disease management impact the incidence of avoidable Emergency Department (ED) visits?

Definition of Terms

The following terms have been identified to assist the literature search process and guide the project.

• Avoidable Emergency Department (ED) Visits: ED visits that could have been avoided or controlled by timely and appropriate care in primary care settings instead of requiring emergency medical attention (Royal, 2022).
• Emergency Department Visits: is a direct personal exchange between a patient and either a physician or a health care provider working under the physician’s supervision to seek care and receive personal health services (“Emergency department visit – health, United States, 2022)
• Chronic Conditions: Long-term medical conditions that need ongoing management and treatment, like congestive heart failure (CHF), diabetes, and hypertension (Greene et al., 2019).
• Patient Education Program: A structured intervention to give patients information, skills, and resources to manage their health conditions effectively, advocate for self-care behaviors, and prevent complications (Royal, 2022).
• Disease management is a systematic method of managing chronic diseases that involves coordinated healthcare interventions and patient self-management methodologies to optimize health results (Williams & Haffizulla, 2021).
• Family Practice Setting: A primary care medical practice that gives comprehensive healthcare services to people and families, including preventive care, acute sickness management, and chronic disease management (Royal, 2022; Greene et al., 2019).
• Evidence-Based Practice: Integrating the best available evidence from studies, clinical expertise, and patient preferences and values to inform decision-making and guide clinical practice to optimize patient results (Royal, 2022).
• Patient Engagement: The active involvement of patients in their healthcare decision-making, treatment planning, and self-management, fostering a collaborative partnership among patients, healthcare providers, and healthcare organizations (Williams & Haffizulla, 2021; Royal, 2022).
• Health Literacy: This is how individuals are empowered to access, digest, and use health information to make personalized choices regarding their health, navigate healthcare systems, and perform self-care behaviors to ensure and enhance their health outcomes (Royal, 2022).
• Primary Care: Comprehensive healthcare services, providing essential healthcare services to patients and conducting initial medical assessment; physicians, nurse practitioners, and physician assistants are the primary providers of healthcare services, and they serve as the first point of contact for individuals seeking medical care and coordinate their ongoing healthcare needs, which include preventive care, acute illness management, and chronic disease management (Greene et al., 2019).

Literature Search Strategies

Several strategies were employed to conduct a comprehensive literature search on factors associated with avoidable emergency department (ED) visits. The databases like PubMed, MEDLINE, CINAHL, and scientific journals were initially searched with extensive use of selection terms, such as “avoidable ED visits”, “frequent ED utilization,” “missed diagnoses in the ED,” and “factors influencing ED utilization.” Boolean operators (AND, OR) were carefully and effectively employed in the search to achieve maximum refinement of search results. Furthermore, the citation chaining technique built up a more comprehensive knowledge of the key areas by reviewing the reference lists of significant articles and systematic reviews. Inclusion criteria were centered on 18 studies published in the last five years written in English and dealt with population groups tied to unavoidable ED trips. The search strategy aimed to tokenize eclectic opinions and approaches to discuss the situation comprehensively.

Literature Review

The study was based on the review of different articles, and based on the content, numerous frequent motifs and contrasting sights were observed. The evidence provides multidimensional ED utilization, which is environmental and patient-related, that contributes to avoidable visits. Researchers concentrate on the impact of individual demographics, the prevalence of health conditions in that society, economic status, and access to medical services as causes of avoidable ED visits (Dufour et al., 2019; Mahajan et al., 2020). In opposition to that, the residual part of this research proves the element of some system problems being manifested in incoherency of the healthcare systems, poor coordination between primary care and emergency departments, and inappropriate provision of alternative care settings (Alnasser et al., 2023; Kim et al., 2019). The future goal toward this direction consists of cutting superfluous ED admissions and improving the process of medical help provision.

Throughout individual studies, finding answers to what makes the desired group of patients (those who need urgent ED services) visit ED may differ in numerous aspects; collectively, they provide in-depth information about the main factors behind frequent and avoidable visits. Nevertheless, to substantiate these arguments, citing direct citations from the publications that report the findings is imperative, thus raising the argument’s authenticity. Thus, the theoretical basis acquired from the literature determines the evidence-oriented strategies that reduce avoidable ED patient health visits and improve healthcare delivery (Cho et al., 2023; Yang et al., 2022).

Alnasser et al. (2023) and Chiu et al. (2023) offer insights into factors associated with non-urgent ED visits within different healthcare contexts. Alnasser et al. (2023) studied the Middle Eastern region, as their research purpose was to find reasons for non-urgent appointments at an academic center in Saudi Arabia. They found that having physical exams, refilling medication requests, and upper respiratory tract infections are the primary reasons non-urgent visits occur, which reveals targeted interventions need to stop unnecessary ED utilization. However, Chiu et al. (2023) further examine the determinants of ED usage among patients who receive visitation services under the income subsidy scheme in Taiwan. They summarize the extent of the communication index, caregiver characteristics, and the duration of the introduction of unhealed ED visits. Both studies reveal that it is important to understand why patients visit the ED when they might have waited for a scheduled appointment. Although the studies were done in different health systems and target different populations, that does not change the importance of knowing the main factors. Alnasser et al. (2023) illustrate a case of non-urgent visits, which take place in an academic medical center in the Middle East, while Chiu et al. (2023) describe patients who were cared for in their homes in Taiwan. These studies also have in common that they emphasize the necessity for patient-oriented approaches to combat the causes of non-urgent ED visits and curb healthcare utilization.

Dufour et al. (2019) designed a systematic review to determine the frequency of ED visitations among senior adults and look for correlations between the variable and the frequency. After analyzing and synthesizing multiple studies, their review identified trends and critical intervening factors as the reason for higher ED usage by older adults. The results exemplified the severely higher rate of care provision for a smaller group of elders, which, in turn, overstrains resources and challenges the offering of senior health care. Therefore, the need for specific approaches to this aim is emphasized. Dufour et al. (2019) highlight past financial resources to pay hospital and emergency department (ED) billings, rural residency, low income, and importing chronic conditions such as heart disease as the primary causes of ED overutilization in aged adults. The findings represent the level of reach of the association between demographic, socioeconomic, and health-related variables and the use of ED in the context of this community. Besides, both Alnasser et al. (2023) and Dufour et al. (2019) focus on the client’s burden of non-emergency ED visits and recommend interventions. Still, the studies reviewed by Dufour et al. (2019) focus on older adults, adding a more specific approach to the elderly group factors.

Also, Cho et al. (2023) and Kim et al. (2019) study factors related to frequent emergency room visits, but the details are in a different context. The research conducted recently by Cho et al. (2023) dug into the matter of Koreans who use emergent departments (ED) frequently because of background and clinical conditions such as cancer and mental illness. Although Kim et al. (2019) focused on social determinants of health in the U.S., they single out the uninsured and Medicaid beneficiaries as a large category of ED infrastructure patients who use emergency rooms for non-traumatic dental treatment. While the studies focus on diverse healthcare settings and patient populations, they both suggest the key role of managing social determinants and societal inequities in ED services.

Furthermore, Mahajan et al. (2020) find out what could cause undiagnosed appendicitis in the realm of ED-based missed diagnoses. It is an emergency condition that tends to be associated with ED visits owing to its acuteness. The work gave a nod to gender, complications, and symptoms such as abdominal pain and constipation as the most probable causes for misdiagnosis. Mahajan et al. (2020) have findings same as those of Alnasser et al. (2023) and Dufour et al. (2019), appertaining to the fact that the true implication of medical care is evaluated based on the patients’ demography and clinical symptoms while they are being treated at the ED. Through her conservation of precise diagnostic situations, mainly concentrating on those with the possibility of misdiagnosis being followed by an ED trip, Mahajan et al. (2020) also add to a macro-level understanding of the factors responsible for inaccurate diagnosis in an emergency room.

On the other hand, Yang et al. (2022) give hints on the pre-event implementation of predictive modeling to prevent avoidable ED visits like old age, chronic diseases, wound problems, and such. While Yang et al. (2022) emphasize specific ailments and conditions, the study of Mahajan et al. (2020) pins the factors that do and do not cause avoidable ED visits. Employing predictive analytical methods, the authors can offer a new method for identifying individuals at high risk of AED visitations. The method that is provided will inform targeted preventive factors that can be aimed at reducing extra healthcare utilization. Conceptualizing distinct study designs, Mahajan et al. (2020) and Yang et al. (2022) enrich comprehension of patient-related determinants and clinical insights associated with the varying uses of the ED and diagnostic precision.

After evaluating and compiling the collective points from the studies addressed above, it is obvious that a multifaceted strategy is needed to take care of the elements that trigger avoidable urgent visits. Alnasser et al. (2023), Chiu et al. (2023), and Dufour et al. (2019) show the crucial role of patient demographics, clinical conditions, and healthcare system specifics in the formation of ED utilization patterns. Alnasser et al. emphasize the importance of non-urgent visits at Middle Eastern academic centers, while Chiu et al. focus on homecare services for patients in Taiwan. Dufour et al.(2019) state in their systematic review that there is a need to devise multifaceted interventions to tackle the different causes that bring people to EDs in different contexts and patient groups,

Other than that, Choi et al. (2023) and Kim et al. (2019), on the contrary, also account for other factors enclosed in the current situation across the whole health system, like maybe the excess visits by patients in the emergency room and the missed diagnoses. Under an identical heading, Cho et al. (2023), Kim et al. (2019), and Mahajan et al. (2020) provide, in fact, a comprehensive description of the factors diminishing the patient outcome, social stratification, and prevalence of correct diagnosis in the emergency setting. These accounts dissimilarly constitute that not only a patient’s condition or its subverts all the dynamics in the ED.

Additionally, Inoue et al. (2023) indicate how demographic characteristics and activities in-home care for elderly persons increase avoidable deaths by using Japan as the case study. Drawing attention to ACSCs and determining the reasons for avoidable ED visits in elderly population receiving home care, Inoue el. al raises the bar concerning measures instituted to avoid unreasonable ED utilization by this healthcare population.

Moreover, Yang et al. (2022) employed the EHR-based methodology in their article to illustrate that the records can help identify patients at risk of avoidable ED visits. Using predictive analytics, the study done by Yang et al. (2022) makes a vital contribution to discovering the program that can be focused on or built to reduce the totality of ED visits by patients. Though various methods of study seem not to be diminishing the papers deliberated in this empirical study, finally forming the synthesis on an understanding of the role of these factors as they influence the provision of ED services, these factors can, hence, be used to support intervention activities aiming at bettering the delivery of emergency services.

Synthesis of the Literature

The literature, in aggregate, underscores the multi-dimensionality of avoidable ED utilization through the intricate interaction of patient demographic factors, clinical conditions, caregivers’ features, and healthcare system elements. While the specific contexts and methodologies vary across studies, the overarching goal remains consistent: to modify the approach to non-urgent ED visits. However, despite the wealth of insights these studies provide, several barriers hinder the effective implementation of strategies to reduce avoidable ED attendance. One significant barrier is the lack of coordination and communication between primary care providers, specialists, and emergency departments. Fragmented healthcare systems often result in patients seeking care in EDs for issues that could be managed in primary care settings without better access and coordination. Additionally, socioeconomic disparities, including limited access to primary care services, transportation barriers, and inadequate health literacy, contribute to the overuse of EDs by certain populations.

Moving forward, addressing these barriers requires a multifaceted approach that involves improving access to primary care and implementing community-based interventions to address social determinants of health. Strengthening primary care services, expanding telehealth options, and promoting public health education are essential to reducing unnecessary ED visits. While the evidence provided by the reviewed studies offers valuable insights into the factors influencing ED utilization, further research is needed to develop and evaluate the effectiveness of interventions to reduce avoidable ED attendance. Longitudinal studies and randomized controlled trials are necessary to assess the impact of various interventions on patient outcomes, healthcare utilization patterns, and healthcare system efficiency. Despite these challenges, addressing avoidable ED visits remains a critical priority for healthcare systems globally. By implementing evidence-based strategies and fostering collaboration among stakeholders, healthcare entities can work towards reducing unnecessary ED attendance, improving patient outcomes, and creating a more efficient and equitable healthcare system.

References

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Appendix G

Individual Evidence Summary Tool

Synthesis and Recommendations Tool

Appendix H