A New Way To Support Frequent Emergency Department Visitors

Photographs by John Everett

As a middle-aged man without permanent shelter, Clayton Gehres, 51, spent a lot of time hanging out at a golf course not far from Ben Taub Hospital, in central Houston, Texas. When he ran out of his psychiatric medications, which happened regularly, his mind would race so much that he’d start drinking to calm his thoughts, he said.

Sometimes he got so strung out on alcohol that he would make his way to the nearby hospital’s emergency department (ED). “I would run out of my medication, so I would start drinking to be able to sleep,” recalled Gehres in a recent telephone interview. “After a while, I’d drink four or five days straight without eating and would go to the hospital. They would help me get back on track, and of course, being homeless for years, I’d do it again.”

Gehres showed up at the ED twenty-eight times in one twelve-month stretch and was admitted for inpatient care on three of those occasions, according to the hospital, which is part of the sprawling Harris Health System. In 2020 he was flagged by a recently launched Harris Health program designed to identify frequent users of emergency services. As staff members recognized his cycle of reappearances and met with him during visits, they gently urged him to seek treatment for his drinking.

“I kind of figured they were trying to help me—they kept asking me, ‘Do you want to go to this program, can we help you do this?’” said Gehres, who moved to Texas from California in 1999 after a prison stint. “They consistently always tried to help me to stop drinking and get help.” At that point, he said, he was ready for a change and accepted the staff’s offer to link him to services in the community.

In December 2020 Gehres enrolled in a sobriety program, graduating the following June. He now lives in and manages a group home and said that he has reconnected with his estranged daughter, who is 23. He last visited the ED in December 2021—and that was for a foot infection.

‘We Build A Relationship’

Harris Health System, a major safety-net provider, serves the 4.7 million people in Harris County, which includes the city of Houston. In addition to Ben Taub, a Level I trauma center with 402 beds in the heart of Houston’s Texas Medical Center complex, Harris Health includes the smaller Lyndon Baines Johnson Hospital, also known as the LBJ, in northeast Houston and an extensive network of clinics and community health centers. Its patient population is diverse: 58 percent Latino, 24 percent African American, 25 percent undocumented, and 54 percent uninsured. County residents without insurance are eligible for services throughout the Harris Health network.

In launching a program for what it calls multivisit patients, or MVPs, Harris Health was seeking to tackle a dilemma that has long bedeviled EDs across the country: A small percentage of patients routinely account for a large share of total visits. Often referred to as “high utilizers” or sometimes “frequent flyers,” these patients experience a range of medical, behavioral, and social conditions and present repeatedly at EDs for reasons generally unrelated to a need for urgent care.

Various studies and medical systems use different thresholds for defining frequent ED visitors and often distinguish between somewhat frequent and very frequent users. Some patients appear five or ten times a year, for example, whereas others show up multiple times in the course of a week, or even a single day. Hospitals recognize that trying to address the complicated needs of these patients in emergency settings is not the best use of health care resources.

“Nonurgent revisits are associated with overcrowding, unnecessary delays in care, dissatisfaction, and avoidable patient harm,” noted a 2017 report on the issue from the Agency for Healthcare Research and Quality.¹ “Since the ED is also an expensive place to receive care, ED revisits can be an important contributor to high health care costs…. Eliminating revisits and inappropriate ED use could reduce health care spending by as much as $32 billion each year.”

The persistence of the problem indicates that medical providers have not yet figured out the most effective way to accommodate patients with challenging behavioral patterns, let alone link them effectively to more appropriate providers than the ED, said Melissa Perez-Halley, a social worker in Harris Health’s population health department, who partners with her director, Priya Khatri, to oversee the MVP program.

“We have to do something different,” she said in explaining the impetus for the program. “The core concept is of meeting the patient where they’re at. We build a relationship with them and help them transition to the outpatient setting.”

The issue of excessive visits to EDs has been a concern for decades. In 2009 a review of studies reported that frequent attendees represented 4.5–8 percent of all users and accounted for 21–28 percent of all visits.² A 2019 review found a similar high-use pattern, with up to 16 percent of total ED users accounting for up to 47 percent of total visits.³ In Massachusetts a state agency reported that in 2019, patients with a history of frequent use made up 1.2 percent of ED patients but 9.4 percent of total visits.⁴

Frequent ED attendees are more likely to have chronic conditions and be heavy users of other health care resources as well as emergency services. Compared with other ED users, for example, the 2019 review noted that these patients “are a disproportionally sicker population, with more complex comorbidities and higher hospitalization rates…. Some of our findings indicate that although many [frequent ED users] have [primary care physicians, that physician] may not be able to meet all the needs because of disease complexity and/or access issues.”

Medical systems have tended to view these patients as inherently noncompliant and their presence in EDs as an unavoidable fact of life. “It’s just the way it was,” said Greg Buehler, the medical director of the MVP program at Harris Health and senior faculty in emergency medicine at Baylor College of Medicine. “We didn’t think there was any way to change it. That was just how these patients utilized the health care system, and we just had to deal with it.”

Jonathan Jones, president of the American Academy of Emergency Medicine, a professional group, said that this attitude is common because the problem is so widespread. “Every hospital has their four or five patients that are just going to come all the time,” said Jones, a community emergency physician in Jackson, Mississippi. In the past year, he said, he’s seen greater awareness in the medical field that the presence of this group in the ED wasn’t “just an annoyance” but “an actual impediment of care to other patients.” He attributed this shift to the ongoing nurse shortage, which has left EDs understaffed. “That just amplifies the effect of people that come frequently—it’s even more noticeable,” he said.

Linking the most frequent ED attendees with case management services has been a standard approach taken by some hospitals to deal with the phenomenon. But case management is a time-intensive intervention and not a systemic solution, said Renee Hsia, a professor of emergency medicine at the University of California San Francisco. “A case manager is one-on-one handholding, like having a primary care physician in every part of your life,” she said. According to Hsia, “there’s been an uptick” in the number of hospitals seeking other ways to address the issue of frequent ED use, “but they vary in how aggressive they are in dealing with it.”

The 2010 Affordable Care Act (ACA) created reimbursement incentives for hospitals to reduce readmissions for inpatient care but did not similarly focus on repeated attendance at EDs. Another part of the ACA, the Medicaid expansion option for states, has had mixed results overall for ED use, although some research has shown a promising impact among regular visitors.

A 2021 study published in the Journal of Emergency Medicine that examined New York State data from the period 2011–16 reported that “the likelihood of frequent ED use [four or more visits within twelve months] decreased 3 years after New York implemented the ACA Medicaid expansion, particularly for Medicaid beneficiaries and the uninsured, highlighting the importance of expanding health insurance and provisions tailored at high-need populations.”⁵

‘Rethink And Redesign’

In 2018 Harris Health created a population health department to assess how it could better address the social determinants of health among its patients. Karen Tseng, a former health care division chief for the Commonwealth of Massachusetts, was recruited to oversee the new department. Tseng, now a special adviser to the Harris Health CEO, said that the ACA’s reimbursement strategy, although mainly targeting excess hospitalization, represented a broader “decade-plus paradigm shift for value-based care” across the health care industry.

“Every responsible participant in the health care system is looking for ways you can improve care, get to better outcomes, and also rethink and redesign the system where it’s not working,” she said.

Reducing frequent ED use presented an obvious target for intervention, as the existing approach benefited neither patients nor hospital.

Reducing frequent ED use presented an obvious target for intervention, as the existing approach benefited neither patients nor hospital. “It was a lose-lose for both,” said Tseng.

In her past work in Massachusetts, Tseng had collaborated with Amy Boutwell, a physician and health care consultant with expertise in the issue of high hospital use. In late 2019 Boutwell began working with the Harris Health ED team on the MVP project, although the advent of the pandemic created some unavoidable disruptions and delays. To start, Harris Health reassigned two community health workers to the project; later, two more were hired.

Implementing changes required Harris Health and its staff to revise their perceptions of high ED use and recognize that it was not a failure on the part of individual patients but an artifact of the current structure of the health care system, said Boutwell, president of Collaborative Healthcare Strategies, a consulting firm in Lexington, Massachusetts. “The dogma in the field is, ‘These patients are unimpactable,’” she said. “We view recurrent high utilization as a symptom. As with any other symptom, there could be many potential underlying causes.”

Given ED use patterns at Ben Taub, MVPs are defined as those coming to the ED fifteen times or more within a year. At the LBJ, the MVP threshold is set at ten visits or more. With these metrics, Harris Health found that in a twelve-month period, 0.7 percent of patients accounted for more than 8 percent of total visits. Specifically, 573 patients accounted for 11,099 visits—an average of almost twenty visits per patient. To determine the specific “drivers of utilization” among the MVPs, the staff reviewed the records and talked with the patients. The most common drivers of utilization among frequent visitors to Ben Taub’s ED turned out to be what the analysis referred to as “pattern, preference, or habit.”

For these patients, in other words, making regular visits to the ED had become a familiar part of their routine, regardless of whether it was an appropriate venue. Among the larger group of all MVPs, patients in the “pattern, preference, or habit” category were the most frequent attendees, each averaging more than fifty ED visits in the previous year. They generally knew that they could stay there for hours before being seen by medical staff and released, said Maureen Ramos, director of nursing at Ben Taub’s ED. Many would come in “under the guise of a medical problem,” she said, and understood that they might get a bed for testing and observation if they complained of something like chest pains or suicidal feelings.

In bringing the scope of the issue to light, Boutwell said, the analysis delivered a real surprise to the hospital. “It was a revelation to the emergency room team, the extent to which people might come with no actual intent of seeking medical care, and they didn’t have a vocabulary for that,” she said. This awareness led to an important question. “I asked the team, ‘We have people who have come to learn that if they come to our waiting room they can spend five or six hours there—what should we do about that?’,” Boutwell said.

In response, the ED changed its processes. All MVPs are now flagged in the Harris Health computer system in preparation for their return. Whenever they visit the ED and their information is accessed, alerts with details about their circumstances and behavior patterns pop up. Staff members know that allowing “pattern, preference, or habit” patients to spend hours waiting to be seen is likely to reinforce their behavior instead of discouraging it. Now the ED staff tries to conduct an assessment and provide any needed medical follow-up expeditiously, Ramos said.

The staff tries to connect MVPs with services and organizations that can address some of the nonmedical needs behind their visits.

“They do the work-up in the most efficient means possible,” she explained. “It doesn’t have to be a room with a bed. It might just be a lab draw.” Some patients protest, she said, because “we’re disrupting their routine.” The key, she added, is “being empathic but consistent” in moving them through the process more quickly. At the same time, the staff tries to connect these MVPs with services and organizations that can address some of the nonmedical needs behind their visits.

In addition to this large and heterogeneous “pattern, preference, or habit” category, Harris Health found other key drivers of utilization. Many patients are experiencing either substance use disorder or mental and behavioral health issues as well as homelessness, Perez-Halley said. In these instances, the staff seeks to assess which of multiple factors might be most implicated in their actions, including their excessive attendance in the ED. “You try to figure out which one is quote-unquote worse,” she said. “If you have someone who is super depressed and is out drinking every night, you realize these people are self-medicating and you try to address the depression.”

For some, especially those arriving at the LBJ ED, the main drivers of utilization are unaddressed medical needs or inadequate supports and services. Many of the patients haven’t been able to access proper treatment, Perez-Halley said, or they don’t know how to navigate social service bureaucracies. Perhaps they are immigrants from countries in which it is common for people to seek primary care at EDs, she added. If their specific concerns or issues can be addressed, the problem of repeated ED visits can often be resolved.

“They might have inadequate support and services, which means they don’t have the right team in place to take care of their needs,” she said. “For example, you have congestive heart failure but you don’t have a cardiologist, so let’s get you a cardiologist. These patients are not really noncompliant, but they don’t know the system, or they don’t understand it, or maybe they don’t have insurance.”

The efforts appear to be having an impact. Since implementing the program, Harris Health says that it has experienced a reduction in ED visits of about 15 percent across all its MVPs. At Ben Taub specifically, between January and September of last year the ED experienced a 77 percent reduction in visits among the highest-frequency users. Harris Health estimates that the cost of each ED visit is around $1,000.

‘Opening Up’

Last March Arturo Herrera began regularly showing up at the ED of the LBJ for dialysis. By mid-June he had sought care there twenty-six times—more than twice a week. “I would come for dialysis every time I felt bad, when I would get tired and would have pain in my chest and back,” said Herrera, 59, who is uninsured and spoke through a Spanish translator. He would routinely wait for hours before being able to receive the procedure, he said.

Given his frequent returns, Herrera soon caught the attention of the MVP program, which assessed his situation and enrolled him in Harris Health’s network for uninsured patients. They were also able to find him a regular slot at the system’s dialysis center. Herrera is now receiving three dialysis treatments a week at prescheduled appointments. “I don’t have to bother them in the [ED] anymore,” he said.

Celia Amaya, a community health worker for the MVP program at Ben Taub, said that it can take a lot of persistence over the course of many ED visits to gain patients’ confidence and fully understand their situation. She is tracking dozens of MVPs at any given time, seeking to connect them with needed services and checking in with them by telephone or text. “You have to be super compassionate, you have to build a lot of trust with them in order to actually address what’s bringing them to the [ED],” she said.

Nery Amaya (no relation to Celia), a community health worker for the MVP program at the LBJ, said that she tries to be as persistent and attentive as possible with patients to develop a relationship. “We don’t give up,” she said. “Some see me and say, ‘Ah, you’re here!’ Others are like, ‘Oh, you again.’ And I say, ‘Yeah, I’m going to come see you every time you’re here.’”

Because some patients tend to visit multiple EDs, Harris Health is now coordinating with two other major area hospitals—Houston Methodist Hospital and Memorial Hermann Hospital—and holding case conferences to discuss mutual patients. In an effort to maximize its reach, the MVP program has also linked up with local organizations providing community-based services, whether related to housing, substance use, or other issues.

The MVP team now regularly meets with its partners, including the Coalition for the Homeless of Houston/Harris County and the Houston Recovery Center, to discuss the management of specific patients. Before this development, said Scot More, a senior associate at the homeless coalition, his organization had little or no contact with EDs. “Our homeless system has been working in a silo, not communicating with the medical services at all,” he said.

Suzanne Jarvis, director of data and program analytics at the Houston Recovery Center, estimated that her organization, which coordinates services for people grappling with substance use disorder, had received more than 120 referrals through the MVP program. Many of the Harris Health MVP referrals, she added, were for people who had not yet landed on the radar of the city’s myriad social service agencies.

“When you start opening up gateways into these bigger systems, you’re catching a new population that wasn’t caught through the social service sector,” Jarvis said. Adequately addressing these patients’ needs, she added, can lead to changes in their patterns of seeking medical care. “We find that if we can house them, if we give them a coach that helps them stay in housing, we get them on medication-assisted treatment, then their use of emergency services goes way down,” she explained.

Ben Ma, the co–medical director of the MVP program at the LBJ and an assistant professor at the McGovern Medical School at UTHealth Houston, said that he learned a great deal more about the ED attendees through the initiative than he expected. “I’ve recognized that this patient population is so complicated and so diverse in a way that I’d never previously thought about,” he said. “Each patient really has their own mixture of barriers, and it takes a pretty robust structure of dedicated people to get to the root of that.”

NOTES

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