Recently implemented care transition program called ED Follow Up Program through the Social Work Department at Elmhurst Hospital targets patients who screen positive for social determinants of health and have frequent Emergency Department (ED) utilization rates. 90-day program provides social support, care coordination and resources to patients based on their social determinants of health as well as helps connects patients to primary care services with the goal of reducing unnecessary ED utilization and preventing hospitalization. Since its inception last year, 350+ patients have been serviced through the program with more than 25% reduction in ED utilization indicating the program’s success.
Problem: Most patients at Elmhurst Hospital belong to low-resource, immigrant communities who fail to transition to primary care from the Emergency Department (ED) due to innumerate barriers, placing them at risk of adverse outcomes. Our program attempts to reduce barriers to accessing follow up care for patients to improve health outcomes.
Measurement: Analysis based on the assumption that 100% of patients enrolled would return to the ED in one year without this program. Number of ED visits, hospitalization rates and clinic ‘No Show rates’ were used as the tools to measure program’s success. Intervention was Plan-Do-Study-Act cycles on a quarterly basis.
Analysis: Used descriptive statistical analysis and charts to show process and outcome measures of patient per month data for number of calls/patients and number of ED visits respectively from program data available for March 2023-202.
Implementation: Program was implemented by 4 team members and program information was disseminated to all ED staff to increase patient screening. Biggest obstacles encountered were the limited resources available for undomiciled patients, undocumented immigrants and asylum-seekers. More collaboration with local Community-based Organizations would vastly improve healthcare delivery and quality of healthcare.
Results/Discussion: Data analysis showed a reduction in ED visits by 71%, reduced hospitalization by 92%, reduced No Show rates by 30%. Care delivery and health literacy were vastly improved for patients. Plan to expand the program for 24/7 coverage and sustain the results by increased knowledge dissemination to the ED staff.
