HMGT 400 DISC 3

American Journal of Emergency Medicine 45 (2021) 578–589

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American Journal of Emergency Medicine

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Emergency department care coordination

strategies and perceived impact under Maryland's hospital payment reforms

will evaluate ED care coordination across an entire state's hospital sys- tem and gather unique insights on physician and staff experiences

1. Introduction

1.1. Background

Care coordination is a broad term that describes the “deliberate or- ganization of patient care activities to facilitate the appropriate delivery of health care services.” [1] Over several decades, care coordination strategies have been employed by emergency departments (EDs) to im- prove access to longitudinal care and address social determinants of health [2]. Prior evaluations of ED-based care coordination interven- tions have demonstrated improved outpatient follow-up, reduced re- peat ED utilization, and reduced avoidable hospitalizations [2,3]. Effective care coordination that can improve outcomes and reduce avoidable hospital use has become increasingly important in a value- based care environment, specifically with alternative payment models (APMs), such as Accountable Care Organizations (ACOs), bundled pay- ment programs, and patient-centered medical homes [4-7].

The state of Maryland (MD) is a pioneer in testing payment re- forms and value-based care initiatives. In 2014, MD expanded its all-payer hospital rate-setting model into a population-based Global Budget Revenue (GBR)model, which replaced fee-for-service hospital payments with prospectively determined global budgets and intro- duced quality pay-for-performance incentives for acute-care hospitals [8,9]. The model has incentivized a shift towards non-hospital care and reduced hospital admissions [10-12]. In 2019, GBR also added a total cost of care metric for the Medicare Fee-for-Service (FFS) popu- lation holding hospitals accountable for Medicare spending across the care continuum [13].

GBR's policy incentives to reduce avoidable utilization call for an in- creasing role for ED care coordination to (1) facilitate safe transitions when patients who may have otherwise been previously admitted are discharged and (2) assist in patient access to community-based ambu- latory health care and social services resources to advance population health in hospital service areas [2,3].

1.2. Importance

EDs comprise a significant portion of hospital care and are the source of more than half of all hospital admissions [14]. The ED also provides needed care when patients lack adequate access to other ambulatory care [15]. The shift from volume-based to value-based payments in fed- eral and state programs has encouraged improved coordination across the care continuum to reduce avoidable utilization [16]. As the health system's safety net and gatekeeper to hospital admission, the ED is

https://doi.org/10.1016/j.ajem.2020.12.048 0735-6757/© 2021 Elsevier Inc. All rights reserved.

therefore uniquely positioned to advance the goals of many of the existing value-based payment models.

Prior research on ED care coordination strategies has typically in- volved single-site evaluations with quantitative measures that provide limited insight on care coordination -processes and in environments with little or no exposure to value-based payments [2,17]. This research

with ED care coordination that can only be acquired through qualitative study. MD's recent reforms make the state an ideal case study to exam- ine the organizational processes of care coordination strategies in re- sponse to value-based payments.

1.3. Goals of this investigation

This investigation has two goals: 1) characterize the scope and vari- ation of ED care coordination strategies in response to MD reforms, 2) describe how physician leaders and care coordination staff perceive the effectiveness of specific strategies. This study also examined the in- fluence of MD's payment reforms on ED care.

2. Methods

2.1. Study design

This is a qualitative interview study of ED physician leaders and care coordination staff in a sample of geographically diverse EDs across the state of MD. In-depth semi-structured interviews were conducted to gather detailed information on the ED care coordination process and understand the focus of care coordination efforts. The interviews assessed the perceived efficacy of care coordination and identified bar- riers to success, as well as the influence of MD's payment reformmodel on ED care coordination strategies. This research studywas approved by the Institutional Review Board at the.

2.2. Study setting and population

Interviewswere conductedwith an interdisciplinary groupof partic- ipants representative of the care coordination process across several EDs. Participants were recruited across MD EDs and provided a diverse representation in ED annual volume (range: 8000–90,000 visits), sys- tem affiliation, and geographic location (inner city, suburban, and rural). Demographic data for the hospital-based EDs represented by study participants was derived from the American Hospital Association database. Two groupswere recruited: ED physician leaders and care co- ordination staff (CCS), with CCS including ED staff positions dedicated to care coordination activities. A total of 25 interviews were conducted across 18 different hospital-based EDs, with 7 EDs having an interview participant from the two recruitment groups.

Table 1 Descriptive characteristics of sampled emergency departments.

Number of Emergency Departments (n) 18 Number of Maryland Counties Represented (%) 42% Annual Emergency Department Volume (mean, IQR⁎)† 53,418 (14,368) Hospital Beds (mean, IQR⁎)† 236 (171) Full-Time Equivalents of Care Coordination Staff (mean, IQR⁎)‡ 6.2 (6.0) Health System Affiliation (%)†

Yes 72% No 28%

Teaching Hospital (%)†

Yes 11% No 89%

Metropolitan Status (%) Inner City 28% Suburban 56% Rural 17%

Descriptive characteristics of Maryland emergency departments represented by semi- structured interview participants. ⁎ IQR represents the interquartile range which is the difference between the third and

first quartile (Q3 – Q1). † Based on data from the American Hospital Association database (2017). ‡ Based on study participant reports in semi-structured interviews.

J.E. Galarraga, D. DeLia, D. Wilhite et al. American Journal of Emergency Medicine 45 (2021) 578–589

2.3. Method of measurement

Interviews were conducted from January through October 2019. In- terviewees were recruited by email using distribution lists of ED physi- cian leaders and care coordination staff in MD. Research participants were identified and recruited on a rolling basis and represented a di- verse array of ED physician leadership and CCS from hospital-based EDs across MD.

A semi-structured interview guide (Appendix Table A1) was de- veloped in collaborationwith subject matter experts in ED care coor- dination. The interview guidewas also testedwithmock participants prior to starting interviews to verify the clarity of the questions and estimate the interview duration, which was 60 min. Interviews were led by a single research team member using the interview guide and responses were transcribed into field notes by a second research team member in real-time. Interviews were also audio recorded to have available for the data analysis phase. The research team contin- ued recruitment until saturation was reached in both groups (phy- sician leadership and CCS), which was assessed as a redundancy in answers with no new emergent themes or codes identified when interviewing staff from additional EDs [18]. Interviews were conducted either in-person or by video conference. When clarifi- cation of interview responses was necessary and the participant permitted contact for potential follow-up questions during the ini- tial interview, the research team followed up with the participant by email.

2.4. Data analysis

The analysis followed an iterative, adaptive grounded theory ap- proach [19]. Participant answers were independently reviewed by two members of the research team to identify analytic domains for the code- book and use thematic analysis to determine prevalent themes [19]. Analytic domains and themes were collated using RedCap, a secure web-based tool that facilitates the creation and management of online databases. Coding was performed in an iterative fashion throughout the interview process. Field notes and transcripts were used to catego- rize responses into the analytic domains generated from the interviews. The codebook was iteratively reviewed with a subject matter expert in ED care coordination to ensure the accuracy and face validity of the framework developed. Once participant answers were coded indepen- dently by twomembers of the research team, any coding disagreements were assessed by the research team and a subject matter expert, with the majority determining the final code. Once all final codes were en- tered, we examined trends and corresponding quotes by thematic category.

3. Results

3.1. Sample characteristics

Descriptive characteristics of the facilities represented by study par- ticipants are summarized in Table 1. Most EDs were affiliated with a health system (72%), based in non-teaching hospitals (89%), and located in suburban areas (88%). The mean full-time equivalents (FTEs) of CCS staff per ED was 6.2 (IQR: 6.03) and the mean FTE/annual ED volume was 0.01 (IQR: 0.006).

Of the 25 participants, 14were physicians in ED leadership positions and 11 were ED CCS. ED physician leadership positions included ED chairs, vice chairs, and medical directors; ED CCS positions included so- cial workers, case managers, and patient navigators. The majority of participants reported having worked four years or more in their ED (n = 18).

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3.2. Descriptive findings of ED care coordination processes

ED care coordination programs varied in terms of their staffing, ser- vices offered, initiatives implemented, and target patient populations. 64% of EDs reported having three or more types of ED-dedicated CCS. The most common ED CCS were social workers (78%), substance abuse peer counselors (67%), and case managers (67%). The majority of ED CCS positions (59%) were introduced after 2014, when GBR policy re- forms were implemented. The most common services included targeted resources for high ED utilizers (94%), home health (89%), and outpatient substance abuse services (83%). (Appendix Fig. A1) Many EDs reported developing relationships with other care settings, including ambulatory clinics (88%) andhospice programs (44%) to accomplish their care coordi- nation goals. Most EDs operated with both ED clinicians and CCS actively identifying care coordination needs and initiating intervention (61%).

Most EDs implemented at least three specific ED care coordination initiatives (94%) in.

the past 8 years, with the majority of the initiatives implemented after 2014 (77%). The most prevalent initiatives were on-site peer re- covery coaches for substance abuse patients (61%), targeted care plans for high ED utilizers to reduce avoidable admissions or readmissions (56%), and urgent outpatient cardiology follow-up for chest pain pa- tients identified as low-risk using the HEART score, a rapid risk- stratification tool based on history, ECG, age, risk factors, and troponin result (44%) [20-23]. There were also several innovative, although less common, initiatives. One included an automated call program, where patients would be navigated to CCS by phone if needing assistance, such as with post-discharge follow-up or medications. (Fig. 2).

ED CCS also reported targeting services for certain patient popula- tions based on socioeconomic status, insurance status, hospital utiliza- tion patterns, and clinical diagnosis. Populations most targeted for ED care coordination were high ED-utilizers (78%), substance abuse pa- tients (50%), uninsured patients (50%), and congestive heart failure pa- tients (50%). (Fig. 3).

3.3. Effective aspects of ED care coordination

As summarized in Fig. 1, multiple thematic categories were identified.

3.3.1. Improved quality and value of patient care When asked to reflect on the efficacy of care coordination in the ED,

the majority of.

J.E. Galarraga, D. DeLia, D. Wilhite et al. American Journal of Emergency Medicine 45 (2021) 578–589

participants (88%) perceived ED care coordination as overall effective. The most prevalent theme identified was the perception that care coor- dination has improved ED care by facilitating safer discharges and improving outpatient follow-up. Participants reported successes in im- proving care transitions to new primary care and specialist providers. They also reported an increased comfort level among ED clinicians with complex patient discharges as a result of care coordination activities. Ad- ditionally, instances where CCS consistently followed up with patients after discharge were identified as successful in improving follow-up rates. Participants also reported that care coordination was effective in addressing social determinants of health (e.g. poverty). Social workers, case managers, and other CCS were described as playing important roles in identifying social issues that impact health and linking patients to specific institutional and community resources, such as food assistance programs, Social Security, and local programs that providefinancial assis- tance for utility bills. (Table 2, Appendix Table A2).

Participants also reported that ED care coordination was effective in reducing hospitalizations, particularly among high ED utilizers, based on personal observations and performance monitoring. They reported that care coordination efforts have reduced costs by reducing hospital resource use. Additionally, participants detailed “super utilizer commit- tees” comprised of a diverse group of clinical providers and CCS who met routinely to develop strategies that address social barriers to reduc- ing avoidable utilization for high ED-utilizers.

3.3.2. Social care integrated into health care delivery The partnership and translation of information between clinical and

care coordination teamswas frequently identified as an effective aspect

Fig. 1. Key analytic domains

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of care coordination. ED clinical providers and CCS were described as having distinct areas of expertise and exchange of information between the two teams reportedly improved care delivery. Care coordination was also seen as playing an important role in identifying socioeconomic challenges often missed by clinicians.

3.3.3. Community partnerships enhancing care transitions To evaluate and improve ED care coordination services, participants

explained that a community feedback loop is fundamental. Some partic- ipants described receiving feedback from all members of the community including patients, family members, other CCS, clinical providers, and community programs, which resulted in an effective continual improve- ment process. However, some described challenges with obtaining com- munity feedback. Many participants reported that CCS were highly knowledgeable about their surrounding communities,with someCCSbe- longing to the same communities as their patients, which helped foster trust. CCS familiarity and relationships built within communities was identified as fundamental to effective ED care coordination.

3.4. Barriers to ED care coordination

Whilemany effective aspects of ED care coordinationwere reported, all participants cited experiences with significant barriers to care coor- dination. (Table 3, Appendix Table A2).

3.4.1. Hospital and patient financial limitations Participants often reported insufficient financial support for care co-

ordination services in their hospital-based EDs, and significant variation

and emerging themes.

Fig. 2. Care coordination initiatives implemented in sampled emergency departments. ⁎PQI pathways represent programs for patients with one of the following Prevention Quality Indicator (PQI) conditions: congestive heart failure, chronic obstructive pulmonary disease (COPD), or pneumonia, and provides urgent outpatient follow-up and care coordination services when patients present to the ED with the condition to reduce avoidable PQI admissions. †Other initiatives include a robocall follow-up program 48-h after ED discharge, a violence prevention program, tailored care coordination pathways for patients with frequent falls, sickle cell pathways to reduce need for admissions, a discharge program for providing inhalers or nebulizer machines if needed to patients with COPD or asthma, and a program coordinatingwith the National Mental Health Group to assist mental health patients.

J.E. Galarraga, D. DeLia, D. Wilhite et al. American Journal of Emergency Medicine 45 (2021) 578–589

in the level of hospital investment in ED care coordination.Many partic- ipants described insufficient care coordination staff coverage, specifi- cally during peak hours of admissions, late in the afternoons and evenings. Participants also commonly noted insurance barriers to care coordination, with uninsured and publicly insured patients often facing challenges because of inadequate coverage for necessary services.

3.4.2. Insufficient outpatient resources Internal and external resource limitationswere also reported by par-

ticipants as limiting the efficacy of ED care coordination efforts. Many participants described challenges in linking patients with primary care providers (PCPs) and noted particular difficulties with finding care for patients without providers. Some participants also reported hesitancy by PCPs in receiving ED referrals because of perceptions that ED patients have low rates of attendance at scheduled appointments. Adequate ac- cess to specialists was also cited as a common barrier, with many spe- cialists having limited appointment availability and geographically sparse, which translates into longwait times and travel distances for pa- tients. Access to long-term care was also a barrier for many patients

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and/or their families who are unable to afford these programs and do not have adequate insurance coverage for long-term care. Some partic- ipants also reported limited community programs to address social de- terminants of health.

3.4.3. Lapses in translating information While many communities were reported as having insufficient re-

sources, in other cases, participants reported that physicians' lack of knowledge about existing community resources was a limitation, espe- cially if CCS did not identify and connect patients to the specific re- source. Also, communication lapses between the clinical, care coordination, and outpatient care teams were described as limiting the efficacy of each party's efforts in patient care. Participants highlighted how ED providers and CCS were often unaware of the care or services patients had already received.

3.4.4. Social challenges and poor patient compliance Patient transportation access was also commonly highlighted as an

obstacle due to patients' physical health, not having someone to

Fig. 3. Target Populations for Emergency Department Care Coordination. ⁎ Specific insurance groups represent public and private payers such as Kaiser,MedicareAdvantage,Medicaid, and others.

J.E. Galarraga, D. DeLia, D. Wilhite et al. American Journal of Emergency Medicine 45 (2021) 578–589

transport them, and/or financial reasons. This led to difficulties in linking patients with outpatient care. Other social determinants were also described as barriers, including undocumented citizenship status, income, housing insecurity, and homelessness. Patient compliance with treatment plans was also an obstacle, particularly among patients with social and cognitive barriers, including the homeless, substance abuse, and mental health populations.

3.5. The perceived impact of MD's hospital global budget program

Most participants perceived MD's reform with global budgeting as having a mixed impact on ED care coordination and overall ED care. (Table 4, Appendix Table A3).

3.5.1. Mixed effects on ED patient care Participants commonly cited GBR as fostering a greater focus on

implementing comprehensive care plans in the ED to address patients' health issues, as opposed to solely assessing specific medical com- plaints. Participants reported that GBR has encouraged a shift towards more holistic care and has prompted an increased focus on care coordi- nation and resources to address social determinants. Participants also reported that GBR incentivized innovations to improve linkages with outpatient care, since rewards for higher patient volume are no longer present.

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On the other hand, many participants also described the negative impact on ED throughput. Participants reported that EDs are dedicating significantly more time and effort to avoid admitting patients, which contributes to increased length of stays and longer wait times, thereby putting patient outcomes at risk. Another reported negative effect was on patient satisfaction, as patientswho expect to be admitted for certain conditions are now managed as outpatients. Participants also reported concerns over the risk of inappropriately discharging patients when hospital care may be the best option, as EDs and hospitals are pressured to reduce admissions and shift towards more outpatient care under GBR.

3.5.2. Increased care coordination resources GBR was reported to result in increased care coordination services,

staffing, and community resources. Participants described how the re- alignment of hospital incentives to reduce avoidable utilization has en- couraged the expansion of care coordination services and the hiring of care management staff. Participants also reported noting an increase in community services made available for patients after MD's adoption of GBR.

3.5.3. Financial outcomes differ by vantage point GBRwas perceived as having amixed impact on finances.Many par-

ticipants described the reduction of hospital resource use, and thereby

Table 2 Reported effective aspects of emergency department care coordination.

Thematic group Representative quotes

Improved quality and value of patient care Safer discharges and improved patient follow-up “Having someone there to make phone calls to primary care providers is huge… because we feel

[more confident] about discharges and follow-ups. This way we can close that loop.” Addresses the social determinants of health to improve outcomes “There are a lot of barriers for our patients that are specifically outside of the medical condition that

brought them in. It is important to be able to have a social worker so that the social determinants are being acknowledged, [which] has been helpful for our patients.”

Reduced hospitalizations “The data has shown that we have reduced readmissions… We've seen a reduction in social admits… We jot down on average fifty plus patients a month that we've either averted a readmission, social admission, or helped in some significant way [to prevent admission]. And this is not just setting up home health; these are people that we feel we've really impacted.”

Social care integrated into health care delivery Translation of information between clinical and care coordination team provides better care

“I know being present and being available and being in the [ED] with the staff has… not only made us [CCS] more visible, but it's done a lot to improve the relationship between the ED providers and care coordination and the hospitalists. They see us as an integral part of the team… and that has made a big difference to be right on the front lines with them.”

Captures issues relevant to patient care missed by the clinical team “It has helped patients function outside of the emergency department and has given them hope for their social issues. Someone comes in for a rash and the care coordination staff is able to find out if you're uninsured, homeless, and possibly in a domestic violence situation.”

Community partnerships enhancing care transitions Community feedback loop to understand outcomes with care coordination and which community resources are best suited for patients

“Relationship building with community health partners has been key. We've had multiple meetings with them, I think it's been great. We think what's been essential to us is getting feedback from them and really trying to get granular on their metrics....to see what the community programs' successes are, what their challenges are...”

Care coordination staff's familiarity with the community builds patient trust

“Definitely what we have…especially the patient navigator… works well. You know that someone is going to call [patients] and follow up with them, and it's someone they can trust rather than just a doctor telling them you need to see a doctor. This is someone who is going to talk to the patient, is from the area, and patients trust [him/her]. It's really nice.

Findings from a sample of 25 semi-structured interviews with emergency department physician leadership and care coordination staff in Maryland.

J.E. Galarraga, D. DeLia, D. Wilhite et al. American Journal of Emergency Medicine 45 (2021) 578–589

reduced expenditures relates to hospital care, as a positive effect of GBR. Participants also highlighted how GBR's fiscal incentives encouraged hospitals to examine population health and invest in strategies to im- prove community supports for patients. Additionally, participants noted that GBR has encouraged providers and staff to become more conscientious of total costs of care. However, participants also noted that GBR puts physician reimbursement at risk, since the program has led to reduced ED volume and ED physicians still operate within a FFS structure. Participants described a financial dichotomybetween EDpro- viders, who operate under a FFS model, and the hospitals they are affil- iated with that operate under global budgets.

3.5.4. Increased strain on ED physicians Participants described ED physicians as experiencing increased

workloads with the pressure avoid admissions. In addition, more bur- den is placed on physicians to handle administrative tasks associated with care coordination when CCS is not available. Relationships be- tween ED providers and hospitalists were also described as being strained by GBR. Some participants described longer discussions and confrontations between ED and inpatient providers about whether pa- tients should be admitted. The increased frequency of these difficult ad- mission debates was reported to have contributed to observations of physician burnout.

3.6. Limitations

This was a qualitative descriptive study not intended to test infer- ences about causation or association. While a diverse sample of partici- pants was recruited for this study, findings are not intended to be generalizable to all EDs. Also, participants in this studymay bemore en- gaged in care coordination than their counterparts, and therefore, may represent EDs with greater care coordination activity than others not sampled in this study.

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The self-reporting nature of this study likely underrepresents the number of services and initiatives implemented at each ED. However, the goal was to further our understanding of common themes across strategies to provide ED care coordination services and to understand the perceptions of staff and physician leaders on the efficacy and barriers for ED care coordination in an environ- ment with aggressive value-based care incentives. Additionally, the qualitative data collection did not include patient perspectives on care coordination experiences, whichmay have provided additional insights on the efficacy and barriers of ED-based care coordination activities.

4. Discussion

MD's value-based care environment has introduced statewide hos- pital incentives to precisely target budgets and reduce avoidable admis- sions. This provides an opportunity to assess how ED care coordination strategies have evolved to help achieve value-based care goals. This study provides unique insights on organizational processes employed for ED care coordination across a diverse group of EDs. It also describes significant variation in the staffing structure and processes for ED care coordination. The observed variation likely reflects the void in established, broadly applicable best practices in ED care coordination, while some variation may also be related to necessary customizations to address unique patient populations.

An important finding is the overall trend towards initiating and expanding ED-dedicated care coordination staffing. We found that 2 in 3 study EDs first started employing dedicated care coordination staff since 2014, while 1 in 3 expanded pre-existing staffing during this time period. Yet, despite this investment, many participants reported there is still insufficient coverage tomeet the demand for care coordina- tion services. This has often led to an onus on clinical providers to ex- pand their scope of work to include more coordination activities,

Table 3 Reported barriers to emergency department care coordination.

Thematic group Representative quotes

Hospital and patient financial limitations Lack or limitations of patients' insurance prevent access to needed care out of the hospital

“One of the biggest barriers is insurance. As great as our cardiology follow-up is, if the patient has a specific insurance they can't go to our cardiologist because they won't be covered and then I don't have a great way of coordinating that. Similarly, insurance seems to stop certain patients from being able to be directly admitted to certain nursing homes or nursing facilities. We all know that's the only thing the patient needs and yet now they're going to have to be admitted to the hospital for days, so I think insurance is a big barrier.”

Inadequate financial support for care coordination services “Unfortunately, we do not have the financial resources for care coordination. We would love to have a case manager or social worker, but this has not been deemed cost effective.”

Insufficient outpatient resources Limited access to PCPs, specialists, and long-term care services to transition care‡

“One of the largest barriers by far is not being able to get patients to a primary care provider. The patient navigators are struggling, calling from place to place trying to get them to take these patients. I understand there is reluctance to take anyone from the emergency department because their no-show rate is pretty high.”

Lack of sufficient staffing coverage to provide care coordination “We need more bodies. We need to be able to have overnight staff coverage as the typical distribution patterns pick up late in the day. We need a care coordination specialist during peak times of admissions.”

Limited community resources that can address social determinants of health

“Any issues I've had have not been because of the hospitals. For me, the hospitals have been patient-focused and patient-centered. The barriers have always been accessing resources in the community…These hospitals can build all of these programs to help patients get what they need, but you need community support for that…There are not enough resources, shelters, Medicaid Assistance programs, and elderly programs. We have difficult patient populations and we need more community resources to support them…”

Lapses in translating information Physician lack of knowledge of community resources “Physicians may not know what the patient needs, what resources are out there for them, or whether

insurance will cover them or not. We need a care coordination expert who is aware of all the resources and needs of patients and is able to match them up for the patient.”

Communication lapses between clinical, care coordination, and outpatient care teams lead to inefficient care transitions

“Communication between the clinical and care coordination team is also a big barrier. There are a lot of people doing good work, but in a silo. Also, there is a gap in communication between outpatient partners and the emergency department, so emergency department providers don't know what has been done since the last time the patients was in the department.”

Social challenges and poor patient compliance Lack of patient transportation access to ambulatory care “A lot of the barriers have to do with patients' ability to get transportation or their ability to have access

to a phone…this makes it difficult for us to communicate with them and their ability to get places that they need to get to. A common complaint in the emergency department is, ‘I couldn't get to my doctor's office so I didn't even bother calling. I don't have anyone that can take me there and I can't take the bus.’

Social determinants as barriers to good health “Patients being insured is a barrier. There is also an undocumented citizen crisis at the hospital. Income is also a barrier. If the patient can't afford it, then they can't afford to get help. Chronic mental illness patients are not able to care for their medical needs as well because they are not addressing their mental health status.”

Poor patient compliance with care plan “Compliance [with care plans] is a barrier for the homeless population, substance abuse population, and mental health population…and problems arise when patients become non-compliant.”

Findings from a sample of 25 semi-structured interviews with emergency department physician leadership and care coordination staff in Maryland.

J.E. Galarraga, D. DeLia, D. Wilhite et al. American Journal of Emergency Medicine 45 (2021) 578–589

which has reportedly contributed to physician burnout as well as wors- ening ED throughput.

There was also predominant trend of implementing new initia- tives to improve care coordination. The most common initiative identified was adopting on-site peer recovery coaches to provide substance abuse counseling and assist patients with navigating both inpatient and outpatient resources for substance abuse. The fact that substance abuse comprises a large portion of avoidable ED visits and there has been an epidemic of drug overdose deaths, with a 137% increase since 2000, has likely motivated these inter- ventions [24,25]. Another important and likely contributing factor is that MD's health department issued grants across the state to support peer recovery coaches, with funding sources incrementally increasing over the past six years [26]. This funding stream outside of global budgets appears to have stimulated the observed focus on substance abuse care coordination. Another common initiative fo- cused on high ED utilizers, particularly those for whom social deter- minants of health contribute to higher use. Prior work has

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demonstrated that these high-cost high-utilizing patients have sig- nificant unmet socioeconomic needs that can be addressed within ED care plans to scale down their utilization [27-33].

The most predominately reported effective aspect of ED care co- ordinationwas improving the safety of higher risk patient discharges from the ED. This has increased clinicians' comfort level when discharging marginal patients to the community, where prompt reli- able outpatient care can be arranged. However, many barriers re- main that limit the efficacy of care coordination. The most highly reported barrier was limited access to outpatient care, including pri- mary care physicians and specialists. This is consistent with prior hospital-based reports evaluating MD's reform model and was cited as a key barrier to care transitions in the inpatient setting by hospital providers in MD [34]. It is thereby important that efforts to reduce avoidable admissions are balanced with investments in the availability of ambulatory care. Even if all efforts to reduce avoidable admissions from the ED and advance ED care coordination are opti- mized, the potential to improve outcomes for discharged patients

Table 4 Reported effects of the global budget revenue model on emergency care delivery⁎.

Thematic group Representative quotes

Positive effects Finance Reduced hospital resource use “A lot of high emergency department utilizers are being followed by transitional care coordinators and

we [the ED] are not seeing them as much. We're reducing avoidable utilization and high emergency department utilizer visits.”

Fiscal incentives to improve population health “Improving population health is a direct result of some of these changes. In the past, it wasn't looked at as much, which is why the resources [were] different. So I would say over the past several years I have seen a change.”

Increased cost awareness of staff/providers “We as providers are more cost conscious, but at the same time if we need to do a test on a patient, we're going to do a test on a patient or order this drug for a patient.”

Patient care Improved quality of care “We're looking at patients more, we're looking at diagnoses more, and we're looking at what is bringing

patients back. Therefore, we're focusing on them more when they come into the emergency department, as opposed to just discharging them home, not admitting them, and dealing with just some of their issues…We're having to look at patients more and implement a plan to help them.”

Holistic care of patients accounting for social determinants “We've seen an addition of all these new resources for patients. We're now recognizing the patient as a whole person and not just a disease.”

Innovations in care delivery for patients “It has realigned incentives such that, as a community, we have had to come up with creative ways to manage chronic illness and manage substance abuse and try to have an effect on these diseases such that they reduce the impact on total cost of care.”

Care coordination Increased care coordination services “I'm not sure that a lot of these [care coordination] services that we have been implemented [would

have occurred] if there wasn't that realignment of incentives with the reforms.” Increased care coordination staffing “I can't speak to policy changes, but we have seen more care management staff brought on…the numbers

have increased.” Increased community resources “Population health is now being looked at more, and I have seen an increase in community services and

providers implementing more support for patients…”

Negative effects Finance Physician reimbursement at risk due to reduced ED volume “Providers and hospitals are definitely in a dichotomy. They [hospitals] are paid for value, but we're

still fee-for-service so [lower volume] impacts us financially where it doesn't necessarily to the hospital.” “Our emergency department volume in our heyday was 105,000 visits, we're down to 92,000, so a huge drop in volume.”

Patient care Delays in ED throughput “Global budget revenue policy reforms have negatively impacted emergency department length of stay

and the complexity of work in the emergency department. We're working extra hard for an extra-long time to not admit patients that we should be admitting. Increased length of stay means long waits, which affects outcomes. Any institution with long waits has bad outcomes.”

Poor patient satisfaction due to expectations for admission “I think patients are a little frustrated. We have some very longstanding patients of the hospital and of the emergency room. Some patients are a little frustrated who used to be admitted for things that they are now getting turned down to be admitted for.” “Maryland doesn't concentrate on the patient experience.”

Risk of inappropriate discharges “It is nice to offer patients outpatient services when appropriate… [but] it's a shame to push patients into outpatient services when they might be better be served in the hospital. I find that to be a big negative.”

Increased Strain on ED Physicians Increased burden on ED physicians “There is burden placed on emergency department providers to make phone calls to the physical

therapist and social worker. Trying to coordinate all of this from the emergency department can be quite time consuming on the physicians.”

Tense relationships between ED physicians and hospitalists “It has impacted interpersonal relationships. For example, every admission now is second-guessed and triple-guessed. You have more confrontations with the medical staff when you try to hospitalize a patient and these discussions go on far longer than they should and it makes the job so much more difficult and it leads to burnout and physician unwellness.”

⁎ Findings from a sample of 25 semi-structured interviews with emergency department physician leadership and care coordination staff.

J.E. Galarraga, D. DeLia, D. Wilhite et al. American Journal of Emergency Medicine 45 (2021) 578–589

will remain limited by the availability of ambulatory care providers. Federal and state policy efforts to expand the availability of nurse practitioners and telehealth for primary and specialty care can ad- dress this access barrier to improve care transitions [35-42].

Insufficient funding for ED care coordination staffing and services was another important commonly cited barrier. Although the Centers for Medicare & Medicaid Services (CMS) reimbursement mechanisms exist for transitional care management in the primary care setting, such reim- bursement mechanisms for care coordination in the ED are not available [43]. The lack of ED care coordination funding mechanisms also persist in payment and delivery reformmodels that focus on improved care tran- sitions, includingMaryland's Primary Care Program implemented in 2019 to support MD's total cost of care goals, which limits the advancement of

585

care coordination staffing efforts [44,45]. Reimbursement strategies that support ED-based care coordination have the potential for cost savings, since its activities are closely tied with reducing avoidable admissions that are drivers of health care costs [46,47]. Prior research examining re- source utilization outcomes with various ED care coordination initiatives have demonstrated its potential for health system cost savings [3,48].

This study also demonstrates that MD's global budgeting reform has stimulated considerable ED-based care coordination initiatives across the state. This suggests that the policy changes have inspired changes in care delivery in alignment with its population health and total cost of care goals. However, the efforts to avoid ED admissions and integrate care coordination services with patient encounters may have also led to unintended negative effects, namely delays in overall ED throughput.

J.E. Galarraga, D. DeLia, D. Wilhite et al. American Journal of Emergency Medicine 45 (2021) 578–589

This is consistent with recent findings from a study examining the ef- fects of MD's global budgets on ED throughput, which identified an in- crease in the length of stay for admitted patients when controlling for other factors [49]. Paradigm shifts like MD's reform that intend to re- duce hospital-based care require an evaluation of emergency care ca- pacity and adequate supports for EDs to sustain the intensity of work required to accomplish the goals of the reform without compromising ED throughput or quality.

5. Conclusions

Across MD, a broad range of new ED care coordination services have emerged, with significant variation in the organizational processes to implement them. MD's broad policy changes to incentivize value- based care have led to notable investments in staffing and innovative programs to improve ED care coordination. ED providers have also com- mitted extra time and effort to avoid admissions and support safe tran- sitions among their discharged patients. The ED is thereby serving a significant role as the bridge between the hospital and non-hospital sec- tors to advance the value of care delivered for MD's health system. Fu- ture developments with evolving value-based care models should consider the role of ED providers to achieve their value-based care goals. Further research is still needed to more comprehensively deter- mine the association of the different strategies to improve ED care coor- dination with patient outcomes to better inform practice leaders and policymakers on the efficacy of the various approaches.

Meeting(s)

Preliminary findings were presented at the American College of Emergency Physicians.

Scientific Assembly in October 2019.

Funding information

This research was supported by the Emergency Medicine Founda- tion Early Career Research Development Grant.

Author contributions

Jessica E. Galarraga conceptualized the study, led semi-structured in- terviews and the development of the codebook for analysis, supervised data analysis, and led the writing of the overall manuscript. Derek DeLia collaborated in the conceptualization of the study, provided senior guid- anceon the interpretation offindings, and revised themanuscript for sig- nificant intellectual content. Daniel Wilhite conducted the data analysis and led the writing of the results. Ronald Romero-Barrientos conducted the data collection, compiled and coded the study's dataset, and collabo- rated inwriting themethods. Kaitlin O'Sullivan contributed to coding the study's dataset and collaborated in writing the introduction. Donna Noccolino served as a subject matter expert and contributed to coding the dataset, interpreting findings, and revising the manuscript for signif- icant intellectual content. Laura Pimentel collaborated in recruitment ef- forts and contributed to the interpretation of findings and critical review of themanuscript. CynthiaWoodcock contributed to the interpretationof findings and critical review of themanuscript. Rollin J. Fairbanks contrib- uted to the study design and provided senior guidance on the interpreta- tion of study findings. Jesse M. Pines collaborated in conceptualizing the study, provided senior guidance on the interpretation of findings, and provided critical revisions to themanuscript. All authors reviewed drafts of the manuscript and approved it for submission.

Declaration of Competing Interest

The authors declare that there are no conflicts of interest.

586

Acknowledgements

The authors would like to acknowledge the leadership of MedStar Health, US Acute Care Solutions, and theUniversity ofMarylandMedical System for their support of this research collaboration. We would also like to specifically acknowledge JonMarkHirshonMD, PhD,MPH, Stuart M. Levine, MD, Walter Atha, MD, David N. Hager, MD, PhD, Richard Ferraro, MD, Eric P. Amli, MD, Jim del Vecchio, MD, Chirag Chaudhari, MD, Stephen M. Schenkel, MD, MPP, Christopher J. Wilbert, MD, Diana M. Pancu, MD, Angela Smedley, MD, Sarah Carle, MD, Daniel Teklay, MD, Brandon J. Cole, MD, and Kevin C. Reed, MD for their support and contributions to this research study.

Appendix

Table A1 Interview guide.

We are working on a study to better understand care coordination services provided for patients in Maryland emergency departments. Care coordination is defined as the organization of patient care activities by healthcare personnel and/or the use of other resources to facilitate the appropriate delivery of health care services. This includes, but is not limited to, discharge planning, arranging access to health services, and patient education activities. Care coordination activities can be executed by various healthcare personnel, such as case management, patient navigators, social workers, nurses, and physicians. We would like to further our understanding of care coordination activities originating in the emergency department and changes in care coordination that may have taken place in response to Maryland's payment reform policies with the Global Revenue Model in 2014.

A. Participant Background Questions:

1) What is the name of the hospital where your emergency department is located?

2) What is your position/title at your emergency department? 3) How long have you been working at your emergency department?

B. Staffing Questions:

1) What type of staff do you have working in the emergency department (ED) that are providing care coordination services?

2) Do you know when staffing for ED care coordination services was imple- mented in your ED?

3) On average, how many total hours of care coordination staffing per week do you have in your emergency department? (e.g. two care coordination staff working from 9 am-5 pm, Monday through Friday, would be 80 h (40 h × 2 staff))

4) Are ED care coordination services available during evening hours, after 5 pm? weekend hours?

C. Care Coordination Questions:

1) What types of care coordination services are provided in your ED? 2) Has your ED implemented any initiatives to improve care coordination for ED

patients? (e.g. initiatives that modify care coordination staffing, modify pro- cesses for care coordination, or target care coordination for a particular clinical condition) If so, please describe.

3) Are there barriers to providing or improving care coordination for patients in the emergency department?

4) Do you think care coordination has been effective in your emergency department?

5) Are there lessons learned from care coordination practices in other health systems that have influenced care coordination in your ED?

D. Maryland Reform Questions:

1) Do you think the recent implementation of Maryland's payment reform with a Global Budget Revenue model has influenced care coordination services pro- vided in your emergency department?

2) Overall, do you think the global budget revenue model has influenced patient care in the ED?

3) Do you have any additional information you would like to share on changes or challenges that have been taking place in your emergency department with Maryland's implementation of the global budget revenue model?

J.E. Galarraga, D. DeLia, D. Wilhite et al. American Journal of Emergency Medicine 45 (2021) 578–589

Fig. A1. Types of care coordination services provided in sampled emergency departments. * Financial assistance includes providing support with paying for medications, utility bills, and other expenses for patients who are low-income. Social services assistance includes helping arrange services such as food stamps and social security. † Insurance navigation represents providing support to uninsured patients in obtaining health care coverage by determiningMedicaid eligibility and startingMedicaid applications in the ED if eligible or navigating patients

T

to alternative sources of insurance coverage if not eligible. ‡Other services include ar- ranging palliative care consults, scheduling diagnostic testing, and linkages with the pa-

tient relations

Table A2 Reported effective aspects and barriers of emergency department care coordination.

Thematic groups

E

Emergent themes

Number of respondents

ffective aspects of care coordination

Patient Care

Safer discharges and improving

outpatient follow-up

9

Reduced hospitalizations

8

B

Addressing the social determinants of health

6

Linkage of patients to community resources

5

Care plans for high ED utilizers

3

Targeted substance abuse peer counseling

3

Improved care for complex patients

2

587

able A2 (continued)

Thematic groups

Emergent themes

Number of respondents

Level of coverage

2

Disease specific care coordination

1

Integrated care delivery

Partnership and translation of information between clinical and care coordination team

5

Capturing issues relevant to patient care missed by clinical team

2

Community Partnership

Community feedback loop

3

Care coordination staff familiarity with community

2

arriers for care coordination

Finance

Lack or limitations of patients' insurance

7

Inadequate finances for care coordination services

6

T

J.E. Galarraga, D. DeLia, D. Wilhite et al. American Journal of Emergency Medicine 45 (2021) 578–589

able A2 (continued)

Thematic groups

L

P

N

Emergent themes

Number of respondents

Resources

Limited access to PCPs, specialists, and long-term care services

10

Lack of sufficient staffing coverage

8

Limited community resources

8

Lack of a feedback loop mechanism

2

Pressure to maintain ED throughput

1

Increased patient wait times

1

Lack of provider time for patient care

1

Physical/Occupational therapy availability

1

Pharmacy availability

1

Care Team Characteristics

Physician lack of knowledge of community resources

2

Physician workload

1

Communication lapses between clinical and care coordination team

1

Patient

Characteristics

Patient

transportation

6

Social determinants of health

5

Patient compliance with care plan

4

Barriers to patient communication

3

Patient support system

2

Inaccurate patient information for follow-up

1

Patient literacy

1

Recidivism

1

Patient missing personal documentation

1

Patient trust of provider

1

imited disclosure of patient information

1

Findings from a sample of 25 semi-structured interviews with emergency department physician leadership and care coordination staff in Maryland. ED = Emergency Depart- ment; PCP = Primary Care Provider.

Table A3 Reported effects of the global budget revenue model on emergency care delivery.

Thematic groups

Emergent themes

Number of respondents

ositive

Finance

Reduced hospital resource use

10

Fiscal Incentives to Improve Population Health

3

Cost awareness of staff/providers

3

Patient Care

Patient care

3

Holistic care of patients accounting for social determinants

2

Incentivizes innovation in care delivery

2

Increased mental health services

1

Care Coordination

Increased care coordination services

10

Increased care coordination staffing

2

Improved community resources

1

egative

Finance

Physician Reimbursement at Risk

1

Reduced ED volume

1

Patient Care

ED† throughput

8

Poor patient satisfaction

4

Shift in inpatient to observation admissions

3

Risk of inappropriate discharges

2

Decreased ED access

1

Poor patient outcomes

1

Patient admittance expectation

1

Provider Experiences

Increased burden on ED† providers

8

Relationships between providers

5

Findings from a sample of 25 semi-structured interviews with emergency department physician leadership and care coordination staff in Maryland. ED = Emergency Depart- ment.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2020.12.048.

588

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Jessica E. Galarraga MD, MPH Health Care Delivery Research, MedStar Health Research Institute,

Hyattsville, MD, United States of America Department of Emergency Medicine, MedStar Washington Hospital

Center, Washington, DC, United States of America Georgetown University School of Medicine, Washington, DC, United States

of America ⁎Corresponding author at: 6525Belcrest Rd., Suite #700, Hyattsville,MD

20782, United States of America. E-mail address: [email protected]

Derek DeLia PhD Health Care Delivery Research, MedStar Health Research Institute,

Hyattsville, MD, United States of America Georgetown University School of Medicine, Washington, DC, United States

of America

Daniel Wilhite BA Health Care Delivery Research, MedStar Health Research Institute,

Hyattsville, MD, United States of America

Ronald Romero-Barrientos BA Health Care Delivery Research, MedStar Health Research Institute,

Hyattsville, MD, United States of America

Kaitlin O’Sullivan MD Department of Emergency Medicine, Emory University, Atlanta, GA, United

States of America

Donna Noccolino BSN, MSN Department of Case Management, MedStar Washington Hospital Center,

Washington, DC, United States of America

Laura Pimentel MD Department of Emergency Medicine, University of Maryland School of

Medicine, Baltimore, MD, United States of America

Cynthia Woodcock MBA The Hilltop Institute, University of Maryland, Baltimore County, Baltimore,

MD, United States of America

Rollin J. Fairbanks MD, MS Georgetown University School of Medicine, Washington, DC, United States

of America Quality and Safety, MedStar Health, Columbia, MD, United States of

America

Jesse M. Pines MD, MBA, MSCE US Acute Care Solutions, Canton, OH, United States of America

Department of EmergencyMedicine, Allegheny Health Network, Pittsburgh, PA, United States of America

24 October 2020