PhD Student, College of Nursing
University of Utah
Introduction:
The Paradigm Shift of Patient Engagement has interwoven research and implication to offer advancements and resources to patients at all levels of care. This meaning that healthcare services have become more readily available for patients at the right place and the right time through emergency care. This concierge care model filled a distinguishable gap in healthcare. However, as healthcare shifts to a care model focused on patient-centered medical homes, some may now question if emergency care is technically the right service by the right provider. Further, emergency care has continued to serve as a convenient service to patients, as primary care and specialty providers face challenges in being available throughout the span of a day/week. In addition, it has become increasingly uncommon for one healthcare profession to provide longitudinal oversight to patients beyond a single setting, which results in fragmented care. This leaves many to wonder if emergency care has negatively reshaped healthcare by increasing healthcare expenditures and siloed the primary care providers from their patients.
The Paradigm Shift of Patient Engagement has interwoven research and implication to offer advancements and resources to patients at all levels of care. This meaning that healthcare services have become more readily available for patients at the right place and the right time through emergency care. This concierge care model filled a distinguishable gap in healthcare. However, as healthcare shifts to a care model focused on patient-centered medical homes, some may now question if emergency care is technically the right service by the right provider. Further, emergency care has continued to serve as a convenient service to patients, as primary care and specialty providers face challenges in being available throughout the span of a day/week. In addition, it has become increasingly uncommon for one healthcare profession to provide longitudinal oversight to patients beyond a single setting, which results in fragmented care. This leaves many to wonder if emergency care has negatively reshaped healthcare by increasing healthcare expenditures and siloed the primary care providers from their patients.
Background of Emergency Care:
The evolution of emergency care in the United Stated was considered a highly successful solution to healthcare’s major challenge and provided a platform with much promise. Further, the additions of Medicare and Medicaid services in 1965 provided an expansion of services and the quality and availability of health care services that was interwoven to push for specialty status. By the 1970’s, the number of American physicians who were specialists were rapidly rising, and the number of general practitioners declined. Hospitals become more modernized through technology advancement. These shifts in healthcare helped to cause the general population to rely on hospital emergency rooms for care.
Retrieved
by History of Emergency Care
The Challenge:
Currently, the
United States healthcare expenditures grew 4.3% in 2016, reaching $3.3 trillion
or $10,348 per person. In terms of GDP, health spending accounted for 17.9
percent. It’s evident that the healthcare has become a complicated system
focused on improvement initiatives to reduce healthcare expenditures and
improve patient outcomes. However, there are many challenges faced as health
systems often showcases the “we’ve always done it this way” type of mentality.
Without room for advancement, the healthcare system may possibly never evolve
to one that is focused on patient-centered initiatives. This may be the very
reason changes in care models are currently focused on incentives and penalties
rather than the simple hunger to do better than we are.
Further, the power of
healthcare interoperability is a platform focused on a central hub of patients’
medical histories despite the location of care. However, no healthcare system
currently mirrors another and there is a lack of mandated protocols currently
in place to ensure effective communication is streamlined to breakdown
fragmented care. Additionally, strategies that have worked historically may
have now become one of the major indicators for failed outcomes such as poor
marketing strategies or the unwillingness to share trade secrets with
competitors to improve patient outcomes.
Lastly, there has been an increase in healthcare provider inability to obtain a healthy work-life balance, which has led to provider burnout amongst physicians and nurses. This often hinders any space for advancement in healthcare models, as this national prevalence has led to patient safety concerns and providers leaving the industry altogether.
The Penalties:
Reflecting back to 2017, more than half of U.S. hospitals were penalized for having hospital readmission rates higher than the acceptable level set by the Centers for Medicare and Medicaid Services (CMS). In addition to the hefty penalties, over 1,621 hospitals were fined five years in a row, earning payment reductions as high as 3 percent. A detailed list of U.S. hospitals facing penalties can be found here: Crimson Advisory Board 2017 Hospital Readmission Penalties
Lastly, there has been an increase in healthcare provider inability to obtain a healthy work-life balance, which has led to provider burnout amongst physicians and nurses. This often hinders any space for advancement in healthcare models, as this national prevalence has led to patient safety concerns and providers leaving the industry altogether.
The Penalties:
Reflecting back to 2017, more than half of U.S. hospitals were penalized for having hospital readmission rates higher than the acceptable level set by the Centers for Medicare and Medicaid Services (CMS). In addition to the hefty penalties, over 1,621 hospitals were fined five years in a row, earning payment reductions as high as 3 percent. A detailed list of U.S. hospitals facing penalties can be found here: Crimson Advisory Board 2017 Hospital Readmission Penalties
Poor Marketing
Strategies:
As our populations are getting sicker, there’s been an increase in the development of healthcare systems, which has diminished opportunities for competitive advantages. As a result, major hospital systems have resorted in marketing and promotional strategies, in order to increase patient census within their emergency rooms, rather than to their competitors.
As our populations are getting sicker, there’s been an increase in the development of healthcare systems, which has diminished opportunities for competitive advantages. As a result, major hospital systems have resorted in marketing and promotional strategies, in order to increase patient census within their emergency rooms, rather than to their competitors.
For example, the
MountainStar campaign displayed above showcases short ER wait times on
promotional billboards in all counties throughout Utah. This strategy seemed to
focus on, ‘the more beds we fill, the more money generated.’ Historically,
these marketing strategies proved to be successful, as it not only catchy, it
most likely steered patients to visit their ERs more often. Unfortunately, this
same marketing has now possibly contributed to the unintended outcomes they are
trying to prevent – reducing readmission rates and avoiding penalties. Although
many factors impact the reasons for readmission, it is still important to note
that these marketing strategies have continued, despite the many efforts primary
care, accountable care organizations and other proactive initiatives have taken
place to prevent readmission. Further, St. Mark’s readmission rates impact is presented
in the figure below, showcasing a significant increase in hospital readmission
penalties.
Retrieved from Readmission Impact -
St. Mark's Hospital
Scenario:
A 87-year-old patient recently discharged from the hospital after a five night stay due to a UTI event. The patient’s daughter is currently taking the patient to the pharmacy to pick up a new prescription upon a primary care appointment. While driving, the patient expressed that she feels a bit nauseous. The daughter becomes panicked and contacts and attempts to contact the primary care via phone. She is placed on hold for several minutes. In this very moment, the daughter and patient drive past a billboard indicating that a particular ER currently has a wait time of 7 minutes. This immediately offers the most convenient option for the daughter, in order prevent delaying care for her mother. She immediately hangs up the phone and heads straight for the ER. Upon admission to the ER setting, the doctor indicates that the patient is just experiencing a common side effect of her antibiotic and just needs to ensure she eats prior to taking the medication.
A 87-year-old patient recently discharged from the hospital after a five night stay due to a UTI event. The patient’s daughter is currently taking the patient to the pharmacy to pick up a new prescription upon a primary care appointment. While driving, the patient expressed that she feels a bit nauseous. The daughter becomes panicked and contacts and attempts to contact the primary care via phone. She is placed on hold for several minutes. In this very moment, the daughter and patient drive past a billboard indicating that a particular ER currently has a wait time of 7 minutes. This immediately offers the most convenient option for the daughter, in order prevent delaying care for her mother. She immediately hangs up the phone and heads straight for the ER. Upon admission to the ER setting, the doctor indicates that the patient is just experiencing a common side effect of her antibiotic and just needs to ensure she eats prior to taking the medication.
Future Direction:
In this particular
scenario, it’s clear it did not warrant a need for emergency care services,
however, from the patient perspective, there genuinely was no other option to
be treated timely than to turn to the ER. In order to overcome the challenges
that have been addressed in this situation, it’s important for healthcare to
lift silos and work collaboratively in sharing services that are not only
convenient to the patient, but also can offer strategies to avoid emergency
care and utilize urgent care services upon screening. Further, marketing strategies
absolutely need to be shifted to a model that offers providers to be available
in a short period time via phone or in-person for triaging matters rather than
indicating the ER is available for non-emergency hours. Lastly,
interoperability needs to take a national precedence to ensure that patients’
health histories at all points of care are available, so providers are able to
serve patient with confidence and avoid duplication of services.
References:
Atzema, C.L., Maclagen, L.C., & Stevenson, M.D. (2017). The transition of care between emergency department and primary care: A scoping study. Academic Emergency Medicine, 24(2), 201-215.
Cameron, P.A. (2014). International emergency medicine: Past and future. Emergency Medicine, 26(1), 50-55.
Koehler, B.E., Richter, K.M., Youngblood, L., & Cohen, B. (2009). Reduction in 30-day postdischarge hospital readmission or emergency department (ED) visit rates in high-risk elderly medical patients through delivery of a targeted care bundle. Journal of Hospital Medicine, 4, 211-218. DOI: https://doi.org/10.1002/jhm.427
Atzema, C.L., Maclagen, L.C., & Stevenson, M.D. (2017). The transition of care between emergency department and primary care: A scoping study. Academic Emergency Medicine, 24(2), 201-215.
Cameron, P.A. (2014). International emergency medicine: Past and future. Emergency Medicine, 26(1), 50-55.
Koehler, B.E., Richter, K.M., Youngblood, L., & Cohen, B. (2009). Reduction in 30-day postdischarge hospital readmission or emergency department (ED) visit rates in high-risk elderly medical patients through delivery of a targeted care bundle. Journal of Hospital Medicine, 4, 211-218. DOI: https://doi.org/10.1002/jhm.427
Photo Credit:
Barker, J. (Photographer). (2018). The Brompton Intensive Care Unit [digital image]. Retrieved from The Sunday Times website: https://www.thetimes.co.uk/article/in-pictures-70-years-of-the-nhs-t6jxldzkv
Barker, J. (Photographer). (2018). The Brompton Intensive Care Unit [digital image]. Retrieved from The Sunday Times website: https://www.thetimes.co.uk/article/in-pictures-70-years-of-the-nhs-t6jxldzkv
Jibe Media. (Photographer). (2012). MountainStar 2012 ED
Outdoor. Retrieved from: http://jibemedia.com/portfolio/40
