Emergency, urgent or primary?

Like much of the U.S., West Michigan is putting up big numbers in the ER. An expert medical team directs patients to the alternatives.

Next time you go to an emergency room, take a close look at the person to your left, then the person on your right.

There’s a good chance one of them doesn’t belong.

In theory, about half of all emergency room visits could be handled someplace other than the emergency room, according to Theresa Osborne, MD, medical director for Spectrum Health Medical Group.

“Emergency departments are set up to deal with trauma, life-threatening illnesses, things like that,” Dr. Osborne said. “They’re not necessarily set up to deal with chronic diseases, which is what a lot of problems are related to.”

That’s not to say emergency room workers can’t handle the hordes of help-seekers who trundle through their doors. They can and they do, every day.

But in about 50 percent of cases, emergency room patients could receive more appropriate and more affordable care from a primary care doctor or an urgent care center, Dr. Osborne said.

While the numbers are that simple, the reality is much more complex.

Dr. Osborne is in her second year as physician leader of a Spectrum Health multidisciplinary team tasked with scaling back patient overuse of the emergency department.

Such overuse is “high, very high,” Dr. Osborne said.

“Since Obamacare has been put into effect, emergency department use is up across the country,” she said. “And people are sort of scratching their heads over this, (wondering) whether it’s pent-up demand or people who put off medical care, or they just haven’t gotten a primary care doctor.

“It’s really disconcerting to a lot of folks,” she said. “It’s driving up the cost, a lot, for everybody.”

The cost issue is, of course, overshadowed by the need to provide patients with proper medical care in the proper settings, Dr. Osborne said.

“We’re not just trying to reduce use—we want to improve outcomes,” she said. “We’re improving quality, too.”

The average cost of an emergency room visit is more than $1,000; a primary care visit is about $70 to $150.

“Clearly, an emergency room visit is much, much more expensive than a primary care visit,” she said.

Still, some patients will choose the emergency room as a first option for minor issues because they have no other place to go–no primary care doctor, or perhaps they’re unfamiliar with urgent care. Others will choose it because they’re uncertain about the severity of their illness.

In all cases, the Spectrum Health system is working to provide resources that will lead patients to the most appropriate and most affordable option, Dr. Osborne said.

“The first thing is to inform the patients and providers that we have many options to receive needed medical care, other than the emergency department,” she said. “There is absolutely no one solution to this. It requires an ongoing effort, communications strategy, all of this, to engage people. It takes time.”

Trending up

In West Michigan, for reasons unknown, folks tend to use the emergency room at a fairly high rate.

Spectrum Health system’s emergency departments logged 242,000 visits last year, the majority of them at the Michigan Street emergency room in Grand Rapids. About 48 percent of all these visits were possibly avoidable, Dr. Osborne said.

“Our numbers are trending up,” she said. “It was trending down for two years, but trending back up this last year.

“Why? We don’t know,” she said. “In one of our practices, we are surveying patients to find out why they’re using it. But there have been many thousands of studies about why people use the emergency department, and a specific best practice that will reduce unnecessary use is not well established.”

The American College of Emergency Physicians released poll results earlier this summer that indicated emergency visits have increased in the U.S.

“Nationally, I don’t think people really know what the reason is,” Dr. Osborne said. “It’s multiple things. It’s really tempting to make these broad statements that it’s because of this or that.”

With the Affordable Care Act, known commonly as Obamacare, now mandating insurance coverage for all, hospital systems are working to help these new customers establish relationships with family doctors. In many cases, this is the first time these customers have had real access to primary care.

“Some people don’t know what that’s like, a primary care doctor,” Dr. Osborne said. “They’ve never had that relationship-based care. We’re trying to help them navigate that system as well.”

Healthy policy experts and medical providers agree that new patients must be quickly plugged into primary care, rather than having emergency departments shoulder the burden.

“This country is currently relying on the emergency department to meet the need for acute, unscheduled care,” Dr. Osborne said. “There needs to be an adequate primary care workforce so that people can get to their care when they want it and need it. It has to be a way that works for them, so they can get the appropriate care at a reasonable cost.”

Right place, right time

When health minds say that 50 percent of emergency room visits could be handled by primary care or urgent care, it’s a number developed in hindsight. Many patients truly don’t know if their symptoms are serious, so they head to the emergency room.

“Where it gets murky is if the patient has a little chest pain and they can’t assess whether it’s really an emergency,” Dr. Osborne said. “So they go where they think they need to go.

“A large majority think they have to go to ER right now, for whatever reason,” she said. “Emergency or not, this is the only place open.”

There are obvious reasons for speeding off to the emergency room, certainly when life or limb is at risk or when the outcome could threaten disfigurement or long-term consequence.

Beyond that, it’s not always so evident.

“The emergency room is a very critical access point for people,” she said. “There’s no way we want to deter people with the appropriate conditions or concerns from going to the emergency department.”

Spectrum Health provides would-be emergency patients, and their providers, with resources to help them choose the appropriate and affordable option for care.

  • Call Us FirstThis campaign is a practical approach that encourages patients to contact their primary care provider first as a source of care. The primary care answering services, available 24-7, offer access to a provider. “Our approach is to help you make the appropriate decision,” Dr. Osborne said. “Call us before you go, so we can guide you.”
  • Clinical Call Center This is similar to Call Us First, insomuch as it leads patients to the best choice for a possibly non-emergent medical condition. The big difference here, however, is the Clinical Call Center is staffed not by primary care offices but by registered nurses who assess patient needs and direct them to the best care source. It can be an important step in getting more patients into urgent care, when appropriate, instead of the emergency room.
  • Integrated care — Spectrum Health’s urgent care system is part of the primary care system, rather than part of the emergency department. It’s an important distinction, Dr. Osborne said, since many other hospital systems integrate urgent care with emergency care. Spectrum Health’s arrangement encourages primary care centers to recommend urgent care as a viable option, rather than the emergency room. It ultimately expands the capacity of the primary care system. Also, with urgent care tied to primary care, Spectrum Health patients “think of it as continuity of care,” Dr. Osborne said. “It’s more coordinated.”
  • Electronic Medical Records — This isn’t a tangible resource, per se, but it’s a critical concept for patients to recognize as they set out to choose the appropriate location for treatment. “All of our urgent care centers use the same medical records as the primary care,” Dr. Osborne said. “This provides more continuity to the patient.” When health care providers have access to the same patient records, it improves communication, efficiency and accuracy, and it better positions workers to recommend options.
  • Care managers — Spectrum Health’s primary care offices also employ care managers who are trained to help patients choose the appropriate service, Dr. Osborne said. “So if you’re a bad diabetic, and you’re working with a care manager, they’ll say, ‘You don’t really need an emergency room, let’s see you here instead,’” she said. “That has been really effective in reducing unnecessary emergency room visits.”

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Comments (7)

  • I am very interested in learning more about a possible initiative to educate the public relative to appropriate places to seek out health advice/care.
    I am an Emergency Dept nurse and I feel that a lot of the decision comes from years of patients NOT knowing what the Emergency Dept is vs. Urgent Care vs. Primary Care. I think there was a certain period of time where we were too busy seeing patients, no matter what and trying to comply with EMTALA rules. We are also afraid of offending the public by attempting to teach them what is appropriate in regards to ED-UCC-PCP.
    Thirty years ago a person’s insurance company would not pay for an emergency dept unless it was deemed an emergency. Something does need to change and I think those at the forefront of medicine could and should be the ones to step forward and lead the change.

    • Monica, right on! Everyone is just trying to do the right thing. We hope that making patients aware of appropriate places to receive needed care outside the ED, expanding our primary care access hours, adding electronic visits as an option for care, and addressing patient concerns more effectively, we will have better healthcare for everyone and less inappropriate use.

  • As another patient who was brought by ambulance to the ED (and then spent a week in the hospital) and had a drunk in the bed on the other side of the curtain in the ED, this was a very interesting piece for me as well.

  • When my doctor tells me I need to go to the ER I refuse as the wait is awful and with my health issues I am exposed to virus that could be treated elsewhere

  • This summer I called my primary was told to go to urgent care it was not open so I ended up in the emergency dept..I had a severe case of gastroenteritis and was given nausea medicine. I did the right thing and ended up in the emergency department because I couldn’t get in to see my doctor.

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