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ED-Based Care Coordination Reduces Costs for Frequent ED Users
Michelle P. Lin, MD, MPH; Bonnie B. Blanchfield, ScD, CPA; Rose M. Kakoza, MD, MPH; Vineeta Vaidya, MS; Christin Price, MD; Joshua S. Goldner, MD; Michelle Higgins, PA-C; Elisabeth Lessenich, MD, MPH; Karl Laskowski, MD, MBA; & Jeremiah D. Schuur, MD, MHS
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ED-Based Care Coordination Reduces Costs for Frequent ED Users

Michelle P. Lin, MD, MPH; Bonnie B. Blanchfield, ScD, CPA; Rose M. Kakoza, MD, MPH; Vineeta Vaidya, MS; Christin Price, MD; Joshua S. Goldner, MD; Michelle Higgins, PA-C; Elisabeth Lessenich, MD, MPH; Karl Laskowski, MD, MBA; & Jeremiah D. Schuur, MD, MHS
Results of our pilot randomized controlled intervention involving emergency department (ED)-based care coordination and community health workers demonstrated a trend toward fewer ED visits, fewer hospitalizations, and lower costs among intervention patients.
Limitations

Our findings are primarily limited by the sample size, which was due to inadequate resources and prevented us from detecting statistically significant effects. A cohort size of 98 (196 total participants) would have been needed to show statistically significant results (P = .05) with 80% power and a 36% reduction in ED visits. Our analysis did not include visits outside our institution; therefore, our patients’ utilization at other hospitals during the intervention period was unknown. However, a majority of patients in both the control and intervention groups had a usual source of care at our hospital, suggesting that these patients would preferentially use our ED for acute care. It is also possible that the results at our urban academic tertiary care hospital may not be generalizable to all institutions. However, the characteristics of our study population (Table) closely mirror those of frequent ED users described in previous studies.10,11 We did not assess ED visit acuity or whether a hospitalization was ambulatory care–sensitive, as we were primarily interested in overall utilization and cost to the hospital.

The promising results of our pilot program were a function of the high productivity of our CHW, the low relative cost of a CHW compared with traditional case managers or social workers, and the high rates of ED utilization by study patients, resulting in more frequent contact between the CHW and frequent ED users. ED visits and hospital utilization may have been impacted by seasonality, as the pilot took place during winter months; however, we still observed greater declines in utilization among the intervention group relative to controls after randomizing. Finally, we did not include data on health outcomes, and the pilot program period evaluated lasted 7 months; further research is needed to assess impact on long-term clinical outcomes, quality, utilization, and cost.

CONCLUSIONS
ED-based care coordination incorporating CHWs and acute care plans is a promising approach to reduce ED visits and hospitalizations and associated costs among frequent ED users. Future efforts to improve quality and efficiency of care for high-cost patients may benefit from collaboration with acute care providers. 

Acknowledgments
The authors would like to acknowledge Carla Pina and Thomas Sequist, MD, MPH, for their important contribution to this work.

Author Affiliations: Icahn School of Medicine at Mount Sinai (MPL), New York, NY; Brigham and Women’s Hospital (BBB, RMK, VV, CP, JSG, MH, EL, KL, JDS), Boston, MA; Harvard Medical School (BBB, RMK, VV, CP, JSG, MH, EL, KL, JDS), Boston, MA.

Source of Funding: Brigham and Women’s Provider Organization Care Redesign Incubator Startup Program (MPL, JDS) and American Board of Medical Specialties Visiting Scholar Award (MPL).

Author Disclosures: Dr Blanchfield, as an employee of Brigham and Women’s Hospital, was paid to evaluate the program being highlighted in this manuscript. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. 

Authorship Information: Concept and design (MPL, BBB, EL, KL, JDS); acquisition of data (BBB, RMK, VV, CP, JSG, MH, EL); analysis and interpretation of data (MPL, BBB, RMK, VV, CP, JSG, JDS); drafting of the manuscript (MPL, BBB, RMK, JDS); critical revision of the manuscript for important intellectual content (MPL, BBB, RMK, CP, JSG, EL, KL); statistical analysis (MPL, BBB, RMK, VV); provision of patients or study materials (MPL, MH); obtaining funding (MPL, KL, JDS); administrative, technical, or logistic support (MPL, MH, KL, JDS); and supervision (MPL, BBB, JDS). 

Address Correspondence to: Michelle P. Lin, MD, MPH, SM, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1620, New York, NY 10029. E-mail: michelle.lin@mountsinai.org.
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