By: Christin Fulton, RN, Director, Population Health Management
Emergency Department (ED) visits are expensive, and a significant number are preventable. Increased use of the ED, especially in non-emergent cases, may indicate lack of access/relationship to primary care, a worsening behavioral or medical health condition, or lack of knowledge on appropriate sites of care for treatment. All these factors contribute to an increase in total cost of care as well as poor management and progression of disease for patients. SoNE HEALTH is dedicated to developing a comprehensive strategy to address avoidable ED use to improve clinical management, improve efficiency and cost of care.
The SoNE HEALTH avoidable ED management program includes interventions that improve access to care, alternative sites of care, patient education and care management programs that help patient coordination with community resources based on their needs.
The SoNE Population Health Management team focuses on outreaching and enrolling our patients into a care management programs that address social barriers to health, education around self-management of chronic conditions, and connecting patients to primary care and other needed resources. Patients enrolled in a care management program receive a Social Indicators of Health (SIOH) screening addressing financial, medication, health access, food, and transportation barriers. The patient is then connected to appropriate resources based on the screening and followed by a care manager longitudinally. The team reviews patients’ chronic conditions and management of those conditions utilizing a self-management action plan, consisting of a zone sheet to help the patient understand which symptoms are normal, those requiring a call to their provider, and those requiring urgent or emergent care. The goal is to equip patients with the knowledge and resources to understand the most appropriate site of care based on their symptoms/condition as well break down barriers to achieving their health goals.
SoNE HEALTH has developed a network of preferred urgent care centers across all of our markets to help patients address urgent, but non-emergent medical conditions. Urgent care is a convenient option for non-emergency medical care. Benefits may include shorter wait times and lower out-of-pocket expense than the ED. The urgent care centers consist of Trinity Health Of New England facilities as well as independent partner facilities.
Most recently, and as part of the ED Diversion strategy, SoNE HEALTH is working in collaboration with DispatchHealth, a mobile urgent care service that can see the patient in their home, reduce visits to the ED for non-emergencies, and collaborate with the patient’s care team on follow up care. The care team at DispatchHealth consists of a virtual physician, a nurse practitioner/PA and a medical technician.
By: Christin Fulton, RN, Director, Population Health Management
