The Working Together to Connect Care (WTTCC) Program establishes partnerships through a shared commitment across hospital departments, government services and community organisations to respond more effectively to individuals who frequently present to the Emergency Department. It achieves this through a seven stage integrated, patient centric model of care.
Working Together to Connect Care Program – Emergency Departments
To provide an enhanced model of care for patients who present frequently to the emergency department (ED) that will improve their long-term outcomes and reduce their dependency on the emergency department.
- Decreased risk of fragmented and iatrogenic care for people with complex psychosocial and medical needs when attending an emergency department.
- Improved community supports for program participants.
- Increased communication, planning of patient care and integration across hospital and community services.
- Decrease to the number of ED presentations, ambulance use and admissions to hospital.
The Working Together to Connect Care program is a combined hospital and community initiative that commenced as a LINK funded project. The main impetus for this program is to identify and provide more inclusive care to a vulnerable group of people who present to the emergency department multiple times. The fundamental underpinning of this program is to facilitate collaboration between participants, their social supports (where applicable) and the healthcare sectors including acute care, primary care and community non-government organisations. Now that the program has been running for two year it is recognised that there is a group of people who rely heavily on an emergency department to provide every day health care needs. This reliance often means that a person who requires seamless care is often fixed in a cycle of disjointed care. All phases of this program work with the person to establish and achieve personal goals, connect to primary care, stabilise housing and sure up a non-fragmented response across EDs and ED presentations.
WTTCC model of care included:
- A flagging system to identify the potential participant.
- MNHHS (internal) Consent and Confidentiality Agreement process to assist with information sharing between government and non-government organisations (NGOs).
- ED referrals to NGO partners.
- Community case management by NGO partners.
- Consumer focused, ED led, multidisciplinary case conferencing and care planning.
- The development and dissemination of an acute management plan (AMP) following case conferences. This is uploaded to The Viewer to improve access for GPs and ED staff.
Activity and costing analysis for inpatient admissions through RBWH ETC based on 108 participants.
- Comparing total presentations for the 5 months pre commencement date (1,345 presentations) to the 5 months post commencement date (1,009 presentations), results in a total of 336 less presentations through the Emergency Department.
- Comparing total admissions for the 5 months pre commencement date (426 separations) to the 5 months post commencement date (299 admissions), results in a total of 127 less admissions via the Emergency Department.
WAU per Inpatient admission:
- Comparing total QWAU / separation in the 5 months pre commencement date (0.72 QWAU / sep) to the 5 months post commencement date (0.83 WAU / sep). An increase in acuity of 15 per cent. This increases the QWAU of the patients admitted in the post period by 33 QWAU (299 admissions x 0.11 acuity increase).
Average length of stay (ALOS):
- Comparing ALOS in the 5 months pre commencement date (2.04 days) to the 5 months post commencement date (1.92 days). A decrease in ALOS of 6 percent.
Occupied Bed Days (OBDS):
- The OBDS has reduced by 292 days in total . The total OBDS in the 5 months pre commencement date (867 days) to the 5 months post commenceent date (575 days).
- Comparing total ambulance usage for the 5 months pre commencement date (75 per cent of ED presentations, 1009) to the 5 months post commencement date (75 per cent of ED presentations, 757), results in a total of 252 less ambulance call outs.
- Decrease risk of agression experienced by staff due to decreased ED presentations (39 per cent of participants have an identified risk of aggresion in the hospital setting).
- Improvement in housing access (71 per cent of people identifying as “no fixed address” have accommodation post commencement of program).
- Decrease in fragmented care when attending multiple EDs (60 per cent attend more then 1 ED), many times a year (112 uploaded, current acute management plans accessible on The Viewer).
- Decrease in episodic care across health care continuums (392 case conferences completed. 20 per cent attended by GP, 4 per cent attended by participants, 14 per cent attended by Alcohol and Drug, 4 per cent attended by QPS, 7 per cent attended by QAS, 36 per cent attended by Mental Health Service and 53 per cent attended by NGO partners).
- Development and implementation of IT solution FrequentED allows sharing of patient centred goals and timely access to valuable clinical information to expedite discharge planning.
- When people have stable housing, attend a GP regularly and are engaged and supported in their community they have less need to attend an ED which flows to a decrease need for admission.
- Community service providers are able to meet the needs of the target cohort and have an in depth understanding of the target cohort.
- This group of people is the most vulnerable in our society and their psychosocial and medical needs are highly complex. Embedded behaviours underpin high use of the health care system.
- Systems integration does not exist across all partners (see partnerships). EDs are not designed to provide continuing health care and ED information technology systems do not support this approach.
Berkowitz, S.A., Hulberg, A.C., Hong, C., Stowell, B.J., Tirozzi, K.J., Traore, C.Y. and Atlas, S.J. (2015). “Addressing basic resource needs to improve primary care quality: a community collaboration programme”, BMJ Quality & Safety, Vol. 25, No. 3, pp. 1-9. Available at: http://qualitysafety.bmj.com/content/qhc/early/2015/11/30/bmjqs-2015-004521.full.pdf (accessed 27 February 2018).
Brennan, J.J., Chan, T.C., Hsia, R.Y., Wilson, M.P. and Castillo, E.M. (2014). “Emergency department utilization among frequent users with psychiatric visits”, Academic Emergency Medicine, Vol. 21, No. 9, pp. 1015-22. Available at: http://onlinelibrary.wiley.com/doi/10.1111/acem.12453/epdf (accessed 27 February 2018).
Chambers, C., Chiu, S., Kativ, M., Kiss, A., Redelmeier, D.A., Levinson, W. and Hwang, S.W. (2013). “High utilizers of emergency health services in a population-based cohort of homeless adults”, American Journal of Public Health, Vol. 103, No. S2, pp. S302-S310. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24148033 (accessed 27 February 2018).
Doupe, M.B., Palatnick, W., Day, S., Chateau, D., Soodeen, R.A., Burchill, C. and Derksen, S. (2012). “Frequent users or emergency departments: developing standard definitions and defining prominent risk factors”, Annals of Emergency Medicine, Vol. 60, No. 1, pp. 24-32. Available at: https://www.sciencedirect.com/science/article/pii/S0196064411018774?via%3Dihub (accessed 27 February 2018).
Fertel, B.S., Hart, K.W., Lindsell, C.J., Ryan, R.J. and Lyons, M.S. (2015). “Patients who use multiple EDs: Quantifying the degree of overlap between ED populations”, Western Journal of Emergency Medicine, Vol. 16 , No. 2, pp. 229-33. Available at: https://www.researchgate.net/publication/274396952_Patients_Who_Use_Multiple_EDs_Quantifying_the_Degree_of_Overlap_between_ED_Populations (accessed 27 February 2018).
Fuda, K.K. and Immekus, R. (2006). “Frequent users of Massachusetts emergency departments: A statewide analysis”, Annals of Emergency Medicine Vol. 48, No. 1, pp. 9-16. Available at: http://www.camconnect.org/member/documents/Fuda_Immekus_2006.pdf (accessed 27 February 2018).
Harcourt, D., McDonald, C., Cartlidge-Gann, L. and Burke, J. (2017). “Working Together to Connect Care: a metropolitan tertiary emergency department and community program”, Australian Health Review, Available at: https://www.ncbi.nlm.nih.gov/pubmed/28248631 (accessed 27 February 2018).
Katz, E.B., Carrier, E.R., Umscheid, C.A. and Pines, J.M. (2012). “Comparative effectiveness of care coordination interventions in the emergency department: a systematic review”, Annals of Emergency Medicine, Vol. 60, No. 1, pp. 12-23. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22542309 (accessed 27 February 2018).
Ku, B.S., Fields, J.M., Santana, A., Wasserman, D., Borman, L. and Scott, K.C. (2014). “The urban homeless: super-users of the emergency department”, Population Health Management, Vol. 17, No. 6, pp. 366-371.
Kumar, G.S. and Klein, R. (2013). “Effectiveness of case management strategies in reducing emergency department visits in frequent user patient populations: A systematic review”, Journal of Emergency Medicine, Vol. 44, No. 3, pp. 717-29. Available at: https://www.sciencedirect.com/science/article/pii/S0736467912011201?via%3Dihub (accessed 27 February 2018).
Liu, S.W., Nagurney, J.T., Chang, Y., Parry, B.A., Smulowitz, P. and Atlas, S.J. (2013). “Frequent ED users: are most visits for mental health, alcohol, and drug-related complaints?”, The American Journal of Emergency Medicine, Vol. 31, No. 10, pp. 1512-5.
Markham, D. and Graudins, A. (2011). “Characteristics of frequent emergency department presenters to an Australian emergency medicine network”, BMC Emergency Medicine, Vol. 11, No. 21. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3267650/ (accessed 27 February 2018).
McCormack, R.P., Hoffman, L.F., Wall, S.P. and Goldfrank, L.R. (2013). “Resource-limited, collaborative pilot intervention for chronically homeless, alcohol-dependent frequent emergency department users”, American Journal of Public Health, Vol. 103, No. S2, pp. S221-4. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3969119/ (accessed 27 February 2018).
Moe, J., Kirkland, S., Ospina, M.B., Campbell, S., Long, R., Davidson, A., Duke, P., Tamura, T., Trahan, L. and Rowe, B.H. (2015). “Mortality, admission rates and outpatient use among frequent users of emergency departments: a systematic review”, Emergency Medicine Journal, Vol. 33, pp. 230-36. Available at: https://www.researchgate.net/publication/275973320_Mortality_admission_rates_and_outpatient_use_among_frequent_users_of_emergency_departments_A_systematic_review (accessed 27 February 2018).
Norman, C., Mello, M. and Choi, B. (2016). “Identifying frequent users of an urban emergency medical service using descriptive statistics and regression analysis”, Western Journal of Emergency Medicine, Vol. 17, No. 1, pp. 39-45. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4729417/ (accessed 27 February 2018).
Ondler, C., Hegde, G.G. and Carlson, J.N. (2014). “Resource utilization and health care charges associated with the most frequent ED users”, American Journal of Emergency Medicine, Vol. 32, No. 10, pp. 1215-19. doi:10.1016/j.ajem.2014.07.013.
Palmer, E., Leblanc-Duchin, D., Murray, J. and Atkinson, P. (2014). “Emergency department use. Is frequent use associated with a lack of primary care provider?”, Canadian Family Physician, Vol. 60, No. 4, pp. 223-29. PMC4046533. Available at: http://www.cfp.ca/content/60/4/e223.long (accessed 27 February 2018).
Pope, D., Fernandes, C.M.B., Bouthillette, F. and Etherington, J. (2000). “Frequent users of the emergency department: a program to improve care and reduce visits”, Canadian Medical Association Journal, Vol. 162, No. 7, pp. 1017-20. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1232308/pdf/cmaj_162_7_1017.pdf (accessed 27 February 2018).
Smith, S. and Chambers, D. (2014) Best practice guidelines, frequent attenders in the emergency department. London: The College of Emergency Medicine, Available at: https://www.rcem.ac.uk/docs/College%20Guidelines/5x.%20Frequent%20Attenders%20in%20the%20Emergency%20Department%28August%202014%29.pdf (accessed 27 February 2018).
Solberg, R.G., Edwards, B.L., Chidester, J.P., Perina, D.G., Brady, W.J. and Williams, M.D. (2016). “The prehospital and hospital costs of emergency care for frequent ED patients”, The American Journal of Emergency Medicine, Vol. 34, No. 3, pp. 459-63. doi: 10.1016/j.ajem.2015.11.066.
Soril, L.J.J., Leggett, L.E., Lorenzetti, D.L., Noseworthy, T.W. and Clement, F.M. (2015). “Reducing Frequent Visits to the Emergency Department: A Systematic Review of Interventions”, PLOS ONE, Vol.10, No. 4. Available at: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0123660 (accessed 27 February 2018).
Vandyk, A.D., VanDenKerhof, E.G., Graham, I.D. and Harrison, M.B. (2014). “Profiling frequent presenters to the emergency department for mental health complaints: socio-demographic, clinical, and service use characteristics”, Archives of Psychiatric Nursing, Vol. 28, No. 6, pp. 420-25. doi:10.1016/j.apnu.2014.09.001.
Vinton, D.T., Capp, R., Rooks, S.P., Abbott, J.T. and Ginde, A.A. (2014). “Frequent users of US emergency departments: characteristics and opportunities for interventions”, Emergency Medicine Journal, Vol. 31, No. 7, pp. 526-34. Available at: http://emj.bmj.com/content/31/7/526.long (accessed 27 February 2018).
Walker, P.A., Cummins, N. and Collins, N. (2015). “Characteristics of frequent presenters to the emergency department: An analysis of 1 year data from an Irish Emergency Department”, PeerJ PrePrints3:e1000v2, https://doi.org/10.7287/peerj.preprints.1000v2 (not peer reviewed). (accessed 27 February 2018).