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Improving care integration: a way to reduce emergency hospitalizations
The number of emergency admissions is growing year by year, but many are not real emergencies, and others are preventable. In this blog post we explore the concepts and levels of integration to outline their impact on emergency admissions and hospitalizations reduction.
Matilde Ferreira
February 23, 2023 · 8 min read
Emergency admissions are both costly and frequently unpleasant experiences for patients. They keep growing year by year, but many are not real emergencies: stable patients are overusing hospitals' resources, urgent patients wait more than recommended, and there's room for improvement on integration with other care levels to reduce readmissions.
Despite the efforts of promising experiences of integrated care models, health care systems remain fragmented, focused on episodic acute care, and unsuitable to provide adequate solutions for today’s societies: aging populations are a reality with no turning back, and approximately one out of three adults suffer from multiple chronic conditions1 often requiring multiple interactions with different providers, making them more vulnerable to fragmented care and frequent admissions in emergency rooms.
Inadequate patient decision-making or healthcare’s inability to adapt to patients’ needs and preferences?
Many people use the Emergency Departments (ED) as their go-to place for healthcare, leading to unnecessary testing and treatment, wasting resources away, and increasing healthcare costs. Patients believe the Emergency Room has higher resoluteness compared with primary care facilities - for instance all the exams are available - and up to 30% of emergency department visits are reported as inappropriate.2,3
Should it be exclusively interpreted as a wrong patient decision? Our guess is “no”, especially considering that around 40% of high-frequency ED users report chronic pain.4 And when the Emergency Room is perceived as the front door for chronic diseases management there is something wrong with the relationship between health systems and patients.
Additionally, within the last decade, the number of emergency admissions for ambulatory care sensitive (ACS) conditions - those where effective community and person-centered care can help prevent the need for hospital admission conditions - and urgent care sensitive (UCS) conditions - acute exacerbations of urgent conditions - increased by 21% and 10%, respectively.5 Even acknowledging some of those are necessary, a high rate may indicate avoidable admissions.
Let’s look at each issue in turn.
- High frequency ED users’ (or simply “high users”) definition is not consensual but four or five visits per year are the most common criteria. Among those people, older age, low socioeconomic status, chronic comorbidities, and high disease burden correlate with increased Emergency Department visits.4
- The insufficient response from primary care, the patients’ perception of greater convenience, accessibility and higher resoluteness of ED care are frequently pointed as root causes for its overuse and wait times.6
- Poor hospital discharge practices lead to unnecessary patient suffering, wasted resources, and readmissions that could be avoided with timely interventions by other care levels.7,8
All in all, integrated strategies are needed to reduce admissions and hospitalizations, strengthen referrals for other care settings, and reduce discharge risks.
Back to basics: what is integrated care?
The World Health Organization and the OECD have repeatedly pointed out integration as an unequivocal necessity for today's health systems, creating opportunities for transforming people’s experiences of care from disjointed to coordinated, reactive to proactive, and service-orientated to personalized, defining it as:
“(…) an approach to strengthen people-centered health systems through the promotion of the comprehensive delivery of quality services across the life-course, designed according to the multidimensional needs of the population and the individual and delivered by a coordinated multidisciplinary team of providers working across settings and levels of care. (…).” 9
In this regard, the Nuffield Trust distinguishes integrated care - an organizing principle for care delivery with the aim of achieving improved patient care through better coordination of services provided - and integration - the combined set of methods, processes and models that seek to bring about this improved coordination of care.10
There are 4 levels of integration:11
- Organizational integration is about policymaking focused on coordinating structures and governance systems across organizations or developing contractual or cooperative arrangements.
- Administrative or functional integration involves joining up non-clinical support and back-office functions in order to share data and information systems across organizations.
- Service integration aims to coordinate different services, such as through multidisciplinary teams, create single referral structures, or single clinical assessment processes.
- Clinical integration promotes care delivery through a single or coherent process, either across professions or care levels. This could involve developing shared guidelines, protocols or patient journeys across boundaries of care.
Some efforts have been implemented on the first level, for example the creation of Local Health Units in Portugal, Integrated Healthcare Organizations (IHOs) in Spain, or even the Five Year Forward View and NHS Long Term Plan frameworks released in England.
The same is observed with administrative or functional integration: some countries like Estonia, Finland, Portugal or Spain are moving forward to implement e-Health records accessible to authorized providers and individuals. However, other challenges remain with the interoperability of data between different systems: a report by the European Commission12 reveals that an interoperable Electronic Health Record (HER) is not in force in most of the systems studied, and many patients cannot easily access and use their data or transfer them between healthcare providers. Interoperable systems between some regions or entire countries are not the majority.
Last, but not least, even more serious issues remain to be addressed when it comes to service and clinical integration. There are few integrated, multidisciplinary, and comprehensive care journeys implemented and referral criteria are unclear, so different care levels are not clinically connected. Additionally, it is still hard to access structured health information, compiled, and updated in real time, according to the evolution of each patient concerning that pathway.
Integrated care with UpHill: strengthen primary care services, support referrals, and avoid preventable readmissions and hospitalizations
Bearing in mind the starting point of this blogpost – reducing inappropriate and preventable admissions and/or hospitalizations – providers need to rethink (and redesign) the processes through which care is delivered to connect fragmented care episodes – that are making them spend too much with avoidable interventions, and patients experiencing poorer outcomes. That is to say, providers need to create continuous, multi-level, multidisciplinary care journeys.
Patient care should not start or even finish at the Emergency Department. Reducing inappropriate and preventable admissions and/or hospitalizations implies strengthening primary care services to keep patients on track all the way long to detect deterioration ahead of time and implementing safe and transparent mechanisms to support the referral of non-urgent patients from EDs to off-site primary and community care services – as recommended by several official frameworks.13,14
How UpHill helps:
- Mapping patient flow across providers;
- Implementing pathway-based decision support for diagnosis and treatment, to upskill generalist physicians and deliver self-sufficient primary care;
- Implementing pathway-based decision support for referral criteria (from prevention to palliation), to always have the patient at the right level of care;
- Strengthening automatic patient stratification through validated questionnaires and scores, that route the patient to the right care setting depending on risk;
- Strengthening automatic post-ED discharge follow-up when appropriate, so physicians can discharge patients safely;
- Strengthening automatic follow-ups for chronic patients with automatic identification of red flags, to conveniently detect patient deterioration ahead of time;
- Monitoring the patient’s progress in real time shared with multi-level care teams, providing a single source of truth for the patients’ needs and history.
There is a consensus that fragmentation of healthcare services particularly hampers the quality of care provided to chronic patients, who often require care from different types of professionals and specialists, as well as a long-term relationship with the healthcare system. In fact, these are a majority of high frequency ED users’, meaning that care integration is also crucial in reducing emergency admissions to hospitals.
This is much more than creating interfaces between different settings: it’s about connecting all the dots for everyone – including healthcare professionals and patients - with a continuous, multi-level, multidisciplinary and digital care journey. A journey that is as predictable as possible, that automatically adjusts according to the patient's progress, that breaks the barriers of traditional care settings and anticipates care needs, avoiding decompensation, emergency admissions, and hospitalizations.
Reach out to us to know more about how UpHill supports healthcare providers working in a coordinated and integrated manner, with a focus on prevention and early intervention, thus ensuring that patients receive the right care at the right time.
References
- Hajat, C., & Stein, E. (2018). The global burden of multiple chronic conditions: A narrative review. Preventive medicine reports, 12, 284–293. https://doi.org/10.1016/j.pmedr.2018.10.008
- Uscher-Pines, L., Pines, J., Kellermann, A., Gillen, E., & Mehrotra, A. (2013). Emergency department visits for nonurgent conditions: systematic literature review. The American journal of managed care, 19(1), 47–59.
- OECD (2017), Tackling Wasteful Spending on Health, OECD Publishing, Paris, https://doi.org/10.1787/9789264266414-en.
- Shergill, Y., Rice, D., Smyth, C., Tremblay, S., Nelli, J., Small, R., . . . Poulin, P. (2020). Characteristics of frequent users of the emergency department with chronic pain. Canadian Journal of Emergency Medicine, 22(3), 350-358. doi:10.1017/cem.2019.464
- Potentially preventable emergency admissions. (2022). The Nuffield Trust. Available at:
https://www.nuffieldtrust.org.uk/resource/potentially-preventable-emergency-hospital-admissions
(Accessed: February 23, 2023). - Boonyasai, R.T. et al. (2014) Improving the emergency department discharge process: Environmental ..., Agency for Healthcare Research and Quality. Available at:
https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/edenvironmentalscan/edenvironmentalscan.pdf
(Accessed: January 30, 2023). - Poor discharge practice leading to 'unnecessary patient suffering' (2015) NICE. Available at:
https://www.nice.org.uk/news/article/poor-discharge-practice-leading-to-unnecessary-patient-suffering
(Accessed: January 30, 2023). - Pham, J.C., Bayram, J.D. and Moss, D.K. (no date) Characteristics of frequent users of three hospital emergency departments, AHRQ. Available at:
https://www.ahrq.gov/patient-safety/settings/emergency-dept/frequent-use.html#intro
(Accessed: January 30, 2023). - Satylganova, Altynai. (2016). Integrated care models: an overview. Copenhagen: WHO Regional Office for Europe; 2016. Available at:
https://www.euro.who.int/__data/assets/pdf_file/0005/322475/Integrated-care-models-overview.pdf
(Accessed: February 22, 2023). - Shaw S, Rosen R and Rumbold B (2011) What is integrated care? Research report. Nuffield Trust. Available at: https://www.nuffieldtrust.org.uk/files/2017-01/what-is-integrated-care-report-web-final_copy1.pdf
(Accessed: February 22, 2023). - Scobie S (2021) Integrated care explained, Nuffield Trust explainer. Available at:
https://www.nuffieldtrust.org.uk/resource/integrated-care-explained
(Accessed: February 22, 2023). - Interoperability of Electronic Health Records in the EU. (2021). The European Commission. Available at:
https://digital-strategy.ec.europa.eu/en/library/interoperability-electronic-health-records-eu
(Accessed: February 22, 2023). - Guidance for emergency departments: Initial assessment. (NHS England). Retrieved February 23, 2023, from https://www.england.nhs.uk/guidance-for-emergency-departments-initial-assessment/#initial-assessment
- Termos de referenciação dos episódios de urgência classificados na triagem de prioridades como Pouco Urgentes/ Não Urgentes/Encaminhamento inadequado para o Serviço (cor verde, azul ou branca, respetivamente) nos serviços de urgência hospitalares para os cuidados de saúde primários e outras respostas hospitalares programadas (ACSS). Retrieved February 23, 2023, from https://apmgf.pt/wp-content/uploads/2022/08/Circular_Normativa_11_2022.pdf
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