Using a Team Approach to Address Avoidable Emergency Department Utilization and Re-hospitalizations as Symptoms of Complexity Through Quality Improvement Methodology

Patients with comorbid medical needs and challenging psychosocial concerns often experience barriers navigating the healthcare system, and may utilize the ED inappropriately or be re-hospitalized within 30 days of discharge. Two concurrent QI projects began by using EMR data to create registries of (a) patients with high ED utilization and (b) patients in need of post-hospitalization follow-up. Both population-based and person-centered interventions, created in partnership with patients, were implemented to better manage the complex nature of the healthcare issues and to stimulate team learning. The interventions included embedding a patient-centered Urgent Plan of Care template into the RN triage system to identify patient concerns beyond symptoms, and creating a new team-based model of hospital follow-up to help discharged patients transition to home, identifying and addressing complex healthcare and social needs. These resulted in significant reductions in ED utilization, increased patient activation and team cohesiveness, and a better understanding of the complexity of the discharged patients’ needs.