Service Utilization by High-Need, High-Cost Patients Following Emergency Department Visits

ABSTRACT

Objective: To compare the likelihood of timely outpatient follow-up care and repeat emergency department (ED) visits and hospitalization among patients with high need and high costs (HNHC) across 4 primary care provider (PCP) types.

Study Design: Our cross-sectional study analyzed 2018 eligibility and claims data of patients with HNHC enrolled in California Medicaid managed care (N = 164,543).

Methods: Outcomes were outpatient follow-up visits for primary care, specialty care, mental health, or substance use disorder (SUD) within 7 days and ED readmission and all-cause hospitalization within 30 days of the first ED visit (index ED). Our independent variable was PCP type, categorized as Health Resources and Services Administration–funded health centers, group practices, solo practices, and other community clinics. Multivariable logistic regression models examined follow-up care utilization by PCP type.

Results: One-third of index ED visits were followed by a primary care (30.3%) or specialty care (31.8%) visit within 7 days. Within 30 days of the ED index visit, approximately 22% had a repeat ED visit and 6% had a hospitalization. Health center patients were more likely to have a primary care, mental health, or SUD follow-up visit than patients of other PCPs and were less likely to have a follow-up specialty visit, ED readmission, or hospitalization.

Conclusions: Findings indicate that health centers have been successful in linking patients to outpatient services that may reduce costly hospitalizations and repeat ED visits but could improve on linkage to specialty care. Improved process-of-care approaches may reduce repeat ED visits and hospitalizations across all PCP types.

Am J Manag Care. 2025;31(11):In Press

Takeaway Points

Findings indicate that health centers have been successful in linking patients to outpatient services that may reduce the need for costly hospitalizations and repeat emergency department (ED) visits but could improve on linkage to specialty care.

• Improved care coordination and integration of specialty care may better address specialty needs of health center patients.
• Improved process-of-care approaches may reduce repeat ED visits and hospitalizations across all primary care provider types.

Efforts to improve population health and costs of care have increasingly focused on reducing emergency department (ED) visits, yet the rates continue to rise, reaching 130 million (40 visits per 100 noninstitutionalized persons) in 2020.^1,2 Approximately 75% of ED visits (97,000,000) result in discharge as opposed to admission to the hospital, and up to 27% are classified as potentially avoidable and unnecessary.^3,4 Estimates indicate that reducing such visits could yield a cost savings of $4.4 billion annually to the US health care system if these visits were managed at outpatient sites.⁵

Interventions to reduce ED visits have targeted patients with high need and high costs (HNHC), defined as individuals with multiple ED visits or hospitalizations; those with a complex health profile indicated by multiple comorbidities, high-morbidity conditions, serious mental illness, or substance use disorders (SUDs); or persons experiencing homelessness or recently incarcerated. The reasons for repeat ED visits by patients with HNHC are multifactorial, but a key aspect is limited access to outpatient care.⁶

Approaches to reduce avoidable ED visits have focused on better care coordination and management, including improved screening of health conditions and connection to specialty care, mental health care, substance use treatment, or social services within primary care settings.⁶ However, these interventions frequently occur after multiple ED visits or hospitalizations and when a patient’s health is more complex.^6-8 Therefore, the effectiveness of these approaches depends largely on timely receipt of outpatient services following discharge from the ED.

Professional guidelines recommend that outpatient providers follow up with patients within 7 days of ED discharge to reduce ED readmissions or hospitalizations.^1,9,10 ED readmissions or hospitalizations within 30 days of the initial visit are considered negative outcomes.¹⁰

Additionally, patients with HNHC are frequently low income, covered by Medicaid, and receive care from safety-net providers including Health Resources and Services Administration–funded health centers (hereafter, health centers).^11,12 These organizations are unique because they provide affordable, accessible, and high-quality primary care services to medically underserved populations regardless of their ability to pay, and they have the potential to reduce ED visits by removing financial barriers to primary care access.^2,13 Studies comparing health center patients with those of other primary care providers (PCPs) have shown that the former have fewer hospitalizations, ED visits, and primary care visits overall compared with patients of private practice or hospital outpatient clinics.^14-16

There is a dearth of evidence to show the pattern of health care use following ED visits among patients with HNHC. This lack of evidence hinders the formation of better solutions to improve HNHC patients’ health outcomes and reduce costs associated with potentially unnecessary acute care. We addressed this gap in the literature by examining the likelihood of timely outpatient follow-up care, including primary, specialty, mental health, and SUD care, for patients with HNHC who received their care from health centers and other PCPs. We also assessed the likelihood of repeat ED visits or hospitalizations in the longer term or 30 days following the visit. For health center patients, we anticipated timelier follow-up of most outpatient visits and less acute care use because health centers offer comprehensive primary care, frequently offer integrated behavioral health services, and employ case managers and care coordinators.¹⁷ However, we anticipated fewer follow-up specialty visits for health center patients because of limited availability of specialists at health centers compared with PCPs in multispecialty groups.¹⁸

METHODS

Our cross-sectional study used 2018 California Medicaid enrollment and claims data for managed care beneficiaries eligible for the Health Homes Program (HHP) created under Section 2703 of the Affordable Care Act, which provided care coordination to high utilizers of acute care.¹⁹ Additional details on HHP and eligibility are available in the eAppendix (available at ajmc.com).

To select our sample, we identified the index ED visit as the first 2018 ED claim followed by discharge. We then included beneficiaries 18 years and older who had at least 1 PCP visit before the index ED visit and excluded those who were not enrolled in the month following the index ED visit. Our final sample included 164,543 adult patients with HNHC. Additional detail on exclusion criteria is noted in the eAppendix.

Dependent Variable

We created several dependent variables to reflect timely follow-up care after the index ED visit. Timely follow-up of outpatient services was defined as any primary care, specialty care, mental health, or SUD visit within 7 days (vs later or no follow-up care). We also created indicators for other follow-up care or ED visits or hospitalizations within 30 days from the index ED visit.¹⁰

Independent Variable

Our main variable of interest was PCP type for each Medicaid beneficiary, categorized as health centers, group practices, solo practice physicians, and other community clinics. We defined PCPs as those in general practice, family medicine, pediatrics, internal medicine, or subspecialties in adult health and geriatric medicine. Additional details on assigning PCP type are noted in the eAppendix.

Covariates

We included several patient- and visit-level covariates that can conceptually influence follow-up care utilization.²⁰ Patient-level covariates included patient demographics (eg, age, sex, race/ethnicity), health status (eg, physical health conditions such as diabetes, mental health conditions such as depression), health care utilization prior to the index ED visit, and a measure of risk for high expenditures. We controlled for the index ED visit characteristics to better understand the reason for the visit and to predict likelihood of follow-up care utilization using Current Procedural Terminology (CPT) codes to indicate intensity of services provided as a proxy for severity and to identify weekend (vs weekday) index ED visits as a proxy for weekend access to primary care. See the eAppendix for additional details on these variables.

Statistical Methods

We conducted descriptive analyses of the sample by PCP types. We then developed logistic regression models to examine the association of PCP type with follow-up visits, controlling for patient and index ED visit characteristics. We included indicators of prior health care utilization that matched the dependent variable of interest in each model (eg, 2 or more prior primary care visits when modeling the likelihood of timely primary care follow-up). We adjusted the SEs in all models to account for the clustering of observations within the same zip codes. We assessed multicollinearity among all variables in our models. We reported predicted probabilities for ease of interpretation using the postestimate margins command and lincom statement to assess significant differences between health centers and other PCP types. We tested whether our designation of timely outpatient follow-up of 7 days following the index ED visit was biased by measuring such visits within 14 days because wait times and the complexity of patients’ needs may result in different follow-up times and behaviors than those suggested by existing guidelines.²¹ In addition, we examined characteristics associated with the first ED visit within 30 days after the index ED visit, including whether it was on a weekend (vs weekday) and service-intensive as indicated by CPT codes. All analyses were performed using R 4.2.3 (R Foundation for Statistical Computing) and Stata 16 (StataCorp LLC), and we reported statistical significance for P values less than .05.

RESULTS

Table 1 shows that the majority of the sample were group practice patients (42.3%), followed by health center patients (29.1%), other community clinic patients (15.7%), and solo practice provider patients (12.9%). One-third of patients received a timely primary care or specialty care visit, and 5.9% and 5.4% received a timely mental health or SUD visit, respectively. Many had an ED visit (22.1%) or hospitalization (6.1%) within 30 days. The rates of timely outpatient and acute care follow-up varied by provider type. Additional characteristics of patients and variations by PCP type are described in the eAppendix. We did not find multicollinearity among covariates.

Table 2 shows predicted probabilities of follow-up care by PCP type after adjusting for patient- and visit-level covariates. Health center patients had a higher predicted probability of having a timely primary care visit (30.9%) than patients of group practice providers (30.2%) and solo practice providers (29.5%) but a lower predicted probability of a timely specialty visit (29.4%) compared with patients of group practice providers (34.3%) and other community clinics (30.6%). Health center patients also had a higher predicted probability of a timely mental health visit than solo practice provider patients (6.1% vs 5.6%) and a higher predicted probability of a timely SUD visit (6.3%) than patients of all 3 other PCP types. Health center patients had lower predicted probability of any ED visit followed by discharge (21.8%) than group practice provider patients (22.5%) and of hospitalization (5.2%) than patients of all 3 other PCP types. The full regression models can be found in eAppendix Table 1.

Several covariates also influenced follow-up care utilization. Notably, predicted probabilities of timely primary and specialty care visits were higher for weekend visits, emergent diagnoses, and more intensive services used during the index ED visit (eAppendix Table 2).

Sensitivity analyses using the follow-up outpatient visits within 14 days were consistent with our findings using 7 days (eAppendix Table 3). In particular, results using the 14-day criteria emphasized that health center patients were more likely to have a primary care follow-up and SUD services than patients of all 3 other PCP types and only less likely to have a timely specialty follow-up compared with group practice patients.

DISCUSSION

The present study provides novel insights into patterns of health care use following ED visits by patients with HNHC from California safety-net PCPs. Our examination revealed that one-third of index ED visits were followed by a timely primary or specialty care outpatient visit, but less than 1 in 10 index ED visits were followed by a timely mental health or SUD visit. These findings were consistent with those of other studies that show a higher rate of outpatient primary care follow-up visits than mental health or SUD visits.^20,22

Our findings also showed that health center patients were more likely than patients of other PCP types to have timely primary care follow-up, which may be facilitated by enabling services provided by health centers, such as care coordination and navigation, to improve patient outcomes. Also, the higher likelihood of mental health and SUD visits for health center patients compared with patients of other PCP types likely reflected higher integration of mental health and SUD providers in these organizations.^23,24 The finding that health center patients were less likely than patients of other PCP types to have follow-up hospitalizations may further reflect the success of health centers’ investments in the provision of comprehensive primary care to meet the needs of their patients, thus reducing the need for further acute care.²⁵ The lower hospitalization rates following index ED visits among health center patients are consistent with previous literature.²⁴ This may be due to health centers’ higher quality of care and care management of patients with chronic conditions vs other providers, which may lead to decreased downstream hospitalizations.^26,27

Despite lower rates of follow-up hospitalizations, we found lower likelihood of timely specialty visits (using either the 7- or 14-day criteria) for health center patients compared with group practice patients. This finding is consistent with evidence that shows that health center patients with Medicaid face barriers to specialty care, such as difficulty finding specialists accepting new patients and the administrative burden required to obtain specialist consultations.^28-31 Our findings are in line with health centers’ focus on primary vs specialty care and other research that indicates lower integration of specialty care at health centers.²⁸ This finding could reflect limitations in current specialty care integration efforts by health centers or challenges with establishing agreements with external specialists to serve the unique needs of health center patients or willingness to see Medicaid patients.³² Comparatively, patients of group practice providers may have fewer challenges to obtain specialty follow-up visits because their PCPs are more likely to practice in multispecialty provider groups.³³

Across all PCP types, the higher likelihood of timely follow-up outpatient visits for patients with HNHC and service-intensive index ED visits indicates greater attention from providers to patients with urgent medical needs and less attention to those HNHC patients with less serious or urgent conditions. These findings may be due to prioritization by the ED to refer patients with more severe needs for follow-up assessment and share information to the PCPs to further coordinate needed care.^34,35 The finding that timely outpatient follow-up care was higher for weekend index ED visits supports the idea that these patients did not have access to outpatient care on the weekend and had to rely on the ED but followed up with their PCP during regular business hours on the weekdays.³⁶ Furthermore, our finding that a notable number of patients had another ED visit or hospitalization within 30 days likely indicates that some patients’ needs were not addressed in the index ED visits or that their conditions worsened. Our analysis of the characteristics of the first ED visit following the index ED visit further corroborated this conclusion.

Limitations

Our study has limitations. We defined the index ED visit as the first ED visit followed by discharge observed in the calendar year, and this visit may be a secondary ED visit for a given patient. However, we controlled for the likelihood of an ED visit in the previous year to partially address this limitation. Our method of attribution of patients to a PCP may be subject to error, and we lacked data on whether patients had switched PCPs during the follow-up period. We also did not have additional information on other characteristics of providers, such as patient management or staffing characteristics, that could impact utilization patterns.

We only assessed the likelihood of 4 types of outpatient care and did not assess whether patients had used other services such as home health that may have kept them from having additional ED visits or hospitalizations. We also lacked data on the use of social services or other types of support that may have addressed patients’ needs following an ED visit.

Our data were restricted to patients with HNHC who were Medicaid managed care beneficiaries in California. Therefore, our data may not be generalizable to patients with HNHC covered by Medicaid living in other states. Our data also did not assess the timely outpatient care or further use of acute care for the universe of patients seen by health centers and other PCPs. Nevertheless, our findings are not complicated by variations in coverage of optional services in Medicaid programs in various states and are highly relevant to Medicaid patients with the most complex needs who are generating the most ED visits and are the focus of intensive efforts to reduce such visits.

CONCLUSIONS

Our findings have implications for policy and practice by PCPs within the safety net. The findings of patients with HNHC visiting the ED on weekends highlight the importance of increasing outpatient access or touchpoints for patients with HNHC when they have acute needs to decrease reliance on costly ED use. One approach may include securing stable and ongoing funding to support health center services for weekend hours or hotlines to provide medical consultations, which have been shown in literature to be effective in reducing ED visits.³⁶ Additionally, other process-of-care approaches—such as ensuring better care transitions, optimizing electronic health record linkages and data sharing between PCPs and EDs, enabling services staff to coordinate care, and using telehealth or telephonic visits—can be considered strategies to improve frequency and timeliness of outpatient follow-up care after an ED visit.^37-39

The lower rates of timely primary care follow-up after patients with HNHC visit the ED for less urgent and less service-intensive reasons indicate that the working relationships between hospital EDs and community-based PCPs may need improvement to ensure patients have continuity of care for their health care needs.⁴⁰ Efforts such as electronic notifications to patients at high risk of frequent ED utilization have been shown to reduce ED recidivism.⁴⁰ This is an important strategy because it may reduce acute care utilization and costs if these patients can receive care in other settings, including primary care. PCPs are frequently the gateway to other needed services, and access to specialty care often requires PCP referrals. In turn, PCPs can also increase their efforts to receive notifications when their patients have ED visits and to assess and address their patients’ needs. Such follow-up requires a patient-centered orientation, appropriate staffing capacity, and delivery of comprehensive and integrated care. PCPs, such as health centers, that have a greater commitment to providing timely access, employing case managers and care coordinators to outreach to patients, and integrating behavioral health care are better equipped to follow up with patients and ensure timely visits after an ED visit.⁴¹

The challenges of obtaining timely follow-up specialty care, particularly by health center patients vs group practice patients, may indicate the need for multilayered efforts to improve care coordination between PCPs within the safety net and specialists for patients with HNHC. Reducing wait times for specialty referral by health plans and increasing the number of specialists in provider networks within the safety net would reduce systemic barriers of underserved communities not having access to specialty care following an ED visit.^18,28 Promoting direct relationships between PCPs and specialists using a memorandum of understanding and PCP use of care coordinators can further increase the likelihood of timely specialty visits.^18,28 Additionally, developing technical assistance resources for PCPs to manage common chronic conditions with specialist consultation may further improve the ability of PCPs within the safety net to provide needed care without waiting for specialist availability.

Lastly, our findings of a higher likelihood of primary care visits within 14 days of the index ED visit further indicate the practical challenges of achieving the 7-day timeline for patients with HNHC on Medicaid, who are likely to have more difficulties obtaining appointments.⁴² Although clinical guidelines have recommended 7 days between ED discharge and outpatient follow-up as the standard for timely follow-up care, there is limited evidence regarding whether this guideline is reasonable for all patient populations.⁴² Future research should investigate further into appropriate follow-up time frames for access to outpatient care, particularly for patients with complex health needs from medically underserved communities.

Author Affiliations: Department of Health Policy and Management, UCLA Fielding School of Public Health (NP), Los Angeles, CA; UCLA Center for Health Policy Research (NP, CL, MH), Los Angeles, CA; now with Los Angeles Department of Public Health, Office of Health Assessment and Epidemiology (CL), Los Angeles, CA; now with the Lewin Group (MH), Falls Church, VA; Bureau of Primary Health Care, Health Resources and Services Administration, HHS (HY-L, BP, MW, TB, HH, AS), Rockville, MD; now with Bureau of Health Workforce, Health Resources and Services Administration, HHS (HY-L), Rockville, MD; now with Center for Medicare and Medicaid Innovation, CMS (BP), Baltimore, MD; now with Office of Planning, Analysis, and Evaluation, Health Resources and Services Administration, HHS (MW), Rockville, MD; now an independent researcher (TB), Washington, DC; now with Department of Justice, Drug Enforcement Administration (HH), Springfield, VA.

Source of Funding: This research was funded by the HHS Health Resources and Services Administration (HRSA) under HRSA contract number HHSH250201300023I. The views expressed in this publication are solely the opinions of the authors and do not necessarily reflect the official policies of HHS or HRSA, nor does mention of the department or agency names imply endorsement by the US government.

Author Disclosures: The 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 (NP, MH, HY-L, BP, MW, TB, HH, AS); analysis and interpretation of data (NP, CL, MH, BP, HH, AS); drafting of the manuscript (NP, CL, AS); critical revision of the manuscript for important intellectual content (NP, CL, HY-L, BP, MW, TB, HH, AS); statistical analysis (MH); provision of patients or study materials (HY-L); obtaining funding (NP); administrative, technical, or logistic support (NP, HY-L, BP, MW); and supervision (NP, HY-L, MW, TB, HH).

Address Correspondence to: Nadereh Pourat, PhD, MSPH, UCLA Center for Health Policy Research, 10960 Wilshire Blvd, Ste 1550, Los Angeles, CA 90024. Email: pourat@ucla.edu.

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