Beyond Camden: Avoiding ER Visits in Massachusetts

A doctor in the emergency room takes a new patient's vitals.

A doctor tends to a patient in the emergency department at a hospital in Hackensack, N.J.

In the Merrimack Valley of Massachusetts, the typical cost for an emergency room visit is about $570. A routine office visit at the Greater Lawrence Family Health Center (GLFHC), however, is only about $130, says Alan Smith, ScD, a behavioral scientist with the center.

In recent years, the center has seen rapid growth in the volume of services provided in emergency rooms at the Lawrence General Hospital in Lawrence and the Holy Family Hospital in neighboring Methuen. Seeking to cut ER usage by 30 percent among its patients, the center implemented a program to identify and care for those who are high utilizers of the ER, Smith says.

For 30 years, GLFHC has provided team-based care to the underserved, many of whom have chronic conditions. In 2011, when the staff learned of the work of Jeff Brenner, MD, and the Camden Coalition of Healthcare Providers, Smith and other GLFHC staff believed Brenner’s methods were ideal for the population the center serves in this working-class city north of Boston.

Coincidentally, the Blue Cross Blue Shield of Massachusetts Foundation also was interested in Brenner’s work and at the time was seeking to fund programs that address health care affordability, says Jessica Larochelle, the foundation’s director of evaluation and strategic initiatives. Brenner's work has been funded for a number of years by the Robert Wood Johnson Foundation, which is also supporting efforts aimed at treating high utilizers at six sites across the country. While the GLFHC work is not funded by RWJF, its goals are in line with RWJF's work on high utilizers.

For every ER visit avoided, the center can save roughly $440. Multiplying that amount many times over increases the chances the GLFHC program will deliver a return on the investment while improving the health of high utilizers.

Under a grant from the Blue Cross Blue Shield of Massachusetts Foundation, GLFHC is testing the theory that the center can deliver better care to the high utilizers among its 52,000 patients and control costs as well. Given that an ER visit costs more than four times what it costs for an office visit, the potential savings are significant.

“For this program, we identified a cohort of 270 patients who met our criteria of a high utilizer, meaning any GLFHC patient who had four or more unnecessary ER visits in a year at either of the two hospitals,” Smith says. “Many of our patients had more than four visits, and some had 16 visits in a year.”

The center defined unnecessary as meaning the patient could have waited 12 to 24 hours and could have visited the clinic because the patient’s condition was not life threatening or urgent. After identifying 270 patients who met the criteria, the center randomly selected 80 patients for inclusion in this program. In each of the past two years, the foundation has awarded the center a grant of $125,000 to study the effects of delivering team-based care to these 80 patients. The team includes a nurse, two medical assistants, a physician, a psychologist, and several residents from the Greater Lawrence Family Medicine Residency program.

For half of the patients in the study, the center assigned a medical assistant to be a health coach. The assistants call each of these 40 patients every month. “We wanted to know if we could make a difference by checking in with them by phone,” Smith says. “We ask how they’re doing and if they need help with anything, such as a medication refill or referrals.”

For the other 40 patients, the center schedules four extra visits annually. “They might come in for other visits, but we wanted to be certain that we would see each patient every quarter to determine if those extra visits would make a difference,” he adds. During the extra visits, the patients meet with their primary care providers. In addition, all 80 patients in the study complete a depression screen (the Patient Health Questionnaire 9: Depression Screener), the UCLA Loneliness Scale, and the SF-36, a 36-question health survey.

Although the center has not yet completed the study under the foundation’s grant, Smith believes the phone calls and extra clinic appointments are cutting the number of unnecessary ER visits. “This could be significant because making these calls and scheduling extra visits are low-cost interventions. The money isn’t there to allow us to go to each patient’s home,” Smith explains. As a Federally Qualified Health Center, GLFHC gets enhanced reimbursement from Medicare and Medicaid by providing comprehensive services to an underserved population on a sliding fee scale.

For all these reasons, the center’s grant application fit the foundation’s goals under its Making Health Care Affordable program, says Larochelle. “Our mission is to expand access to health care in Massachusetts. To preserve the coverage gains our state has achieved, we have to get costs under control,” she adds. “Right now, we want to contribute to advancing ideas that show promise for cost containment.”

Before the foundation’s funding runs out next summer, Smith hopes to show that providing targeted care to high utilizers saves more money than it costs. For every ER visit avoided, the center can save roughly $440. Multiplying that amount many times over increases the chances the GLFHC program will deliver a return on the investment while improving the health of high utilizers, Smith concludes.

In Practice

Three Criteria Define an Unnecessary ER Visit

The Greater Lawrence Family Health Center identifies an unnecessary visit to the ER as follows:

  • The visit happened when the health center was open, meaning a regular source of primary care was available.
  • The visit was not urgent and could have waited 12 to 24 hours.
  • The visit did not involve any bleeding or trauma.