At Jackson Memorial Hospital in Miami, patients using the emergency department when they actually need preventative care costs the public health system millions of dollars every year. But about two years ago, the administration decided to do something about it.
In 2017, the Jackson Health System started a temporary program — initially for 120 days — in an effort to better manage the medical conditions that brought people in and out of the main hospital’s emergency department like a revolving door.
What the staff running the program quickly learned was that the patients had other issues in their lives: homelessness, mental illness, lack of a primary care provider, no cell phone and, often, no means of transportation. By addressing those roadblocks and getting patients into preventive care, Jackson could save taxpayer money — potentially, a lot of it.
Today, the “emergency department care transition program” has grown beyond its initial trial run and has saved an estimated $3 million, according to Plante Moran, a group of financial advisors who consulted Jackson Health on the program. The focus on preventing unnecessary emergency department use has become a permanent fixture of Jackson’s population health department, which relies on a custom algorithm built to identify Miami’s most frequent emergency department visitors.
“One of the things we found in our patient population was that since they didn’t have a primary care physician .... they would go to the[emergency department] for something as simple as a medication refill,” said Stephanie Schmidt, director of population health management at Jackson Health System.
The computer code helps Schmidt’s team find Jackson patients who are uninsured or under-insured, have no primary care physician of record and have visited the emergency department five or more times in the prior year.
Once identified by the algorithm, patients are assigned case managers who help arrange transportation for physician visits, accompany them to the doctor’s office and monitor their progress. Schmidt said her team found early on that the people using the emergency department most often might just not know where else to go.
The consultants at Plante Moran estimated that Jackson Health saved about $3 million from the first 100 patients to “graduate” the program. It calculated the savings by comparing the cost of their treatment with the projected cost of their ongoing use of the emergency department, which averages about $2,100 a visit, if the case managers had not intervened.
The emergency department transition program has since looked at the cases of about 1,500 patients, and Jackson Health is still analyzing the savings from the initiative’s expansion.
When the staff at Jackson looked at a two-year sampling of the most frequent patients at the emergency department, they found that at least 28 percent had experienced homelessness. About 49 percent had a diagnosis related to mental or behavioral health disorders. And about 25 percent had a diagnosis of schizophrenia or delusional disorders.
Once a patient agrees to participate in the program, the population health department assigns them a case manager, or “population health specialist. The specialist then makes themselves available to the patient 24 hours a day, seven days a week, by cell phone.
On average, Schmidt said, case managers work with a patient for 6 1/2 months, offering advice on how to follow a care plan, get to appointments and manage medication. A lot of what the case managers are doing, Schmidt said, amounts to instilling good habits and behaviors.
“We provide a lot of support, but on the way, we are careful to teach them how to navigate the system and the care,” she said. “They need to learn how to take care of themselves, because what we don’t want to do is have them create a dependency on us so that when it comes time to transition them, they feel ill prepared.”
Much of the innovation in the program is driven by technology. Jackson Health had its Internet Technology department design the algorithm, and the system alerts case managers whenever a patient assigned to them shows up at any Jackson facility.
That could mean a scheduled appointment with a physician, or an unplanned 2 a.m. emergency department visit.
“This comes as a surprise to the patients, because they’re like, ‘How did you know that I went there?’” Schmidt said. “We tell them we can see everything they’re doing. That’s the point: we want to know everything about you.”
That element of the program could continue to grow as more technology is introduced. One such possibility is “wearables,” or medical monitoring devices that patients would wear, like blood pressure cuffs or blood sugar monitors for diabetes. The electronic devices would then send information to Jackson, giving case managers access to real-time health data from the patients in the program.
Jackson Health plans to expand the program, although finding case managers to handle such a complex patient population has been a challenge, according to Barbara Fonte, vice president of managed care and population health.
Fonte said Jackson has had to deal with managers burning out “once they feel the intensity of dealing with this patient population” and the frustration of trying to surmount the barriers to care for people who are homeless or have mental health issues.
“This isn’t something that people necessarily study for,” she said. “It isn’t a degree that you’re prepared for an you know exactly what you’re going to deal with.”
Schmidt said that case managers also deal with a certain degree of distrust from the patients, but that typically gives way to a better relationship as they make progress.
“We really need to get them to trust us, to open up, and it’s a humbling thing for people that are sort of sharing their social needs, their life struggles,” she said. “We have to engage them somewhat on a slow basis, and let them know who we are.”