RESEARCH QUESTION AND DESIGN 2
Research Question and Design
Emergency department crowding and overuse is becoming an increasing problem for
many hospitals within the United States (Berkowitz et al., 2018; Bilazarian et al., 2021;
Goncalves et al., 2022; Hsuan et al., 2023). Associated with overcrowding is an increase in
healthcare costs (Bilazarian et al., 2021), reduced patient safety (Zodda & Underwood, 2019),
and increased length of stay and mortality (Hsuan et al., 2022). While they account for only a
small portion of annual visits to emergency departments, high-need, high-cost users have been
identified as one patient population, placing strain on an already overtaxed system (Bilazarian et
al., 2021). High-need, high-cost patients are identified as those with 10 or more visits to the
emergency department in 12 months. This group of patients uses a significant amount of time
and resources allocated to the emergency department and reduces the quality of healthcare
provided to all patients presenting to the emergency department, some of whom have life-
threatening injuries and medical events (Gonçalves et al., 2022).
Problem Overview
High-need, high-cost users of the emergency department are often identified as those
with chronic health conditions, including those with psychiatric diagnoses (Bilazarian et al.,
2021; Goncalves et al., 2022; Hastings et al., 2019; Shrapnel et al., 2019). Emergency care is
costly, and millions of dollars are lost annually through unreimbursed healthcare obtained in the
emergency department (Hastings et al., 2019). Patients discharged from emergency departments
are often given a packet of paperwork explaining their diagnosis and often instructed to follow
up with their primary care provider within a certain number of days. Patients have identified poor
case management, lack of trust in the healthcare system, and inability to follow up in a timely
manner as major contributors to repeat emergency department visits (Chang et al., 2021).
RESEARCH QUESTION AND DESIGN 3
As more payors turn from a fee-for-service to a value-based care reimbursement system,
hospitals are facing increased pressure to reduce the number of these frequent visits or risk losing
reimbursement for services provided (Berkman et al., 2021). Nursing leaders within the
emergency department are often tasked with finding solutions to reduce the number of
unreimbursed dollars to their cost center. A literature review shows that several innovative
approaches have been implemented to aid patients in post-discharge care and reduce repeat
visits. However, current available research is mixed on how effective follow-up programs aimed
at reducing frequent repeat visits are at reducing unreimbursed medical costs.
As a faith-based organization, XXXX is dedicated to reaching every patient in a way that
brings honor and glory to God by XXXXXX to all they care for. It is important to remember that
every human being was created in the image of God (King James Bible, 1769/2024, Genesis
1:27, 9:6), and all care given should reflect Christ’s love (King James Bible, 1769/2024,
Matthew 25:35-40). As an organization, it is also essential to follow Biblical principles regarding
stewarding resources (King James Bible, 1769/2024, Genesis 2:15; Matthew 25:14-30; Luke
12:48; Galatians 6:7).
As the literature indicates, post-discharge follow-up care is lacking and is one cause for
increased repeat visits to emergency departments, leading to unreimbursed dollars for the
healthcare organization (Berkman et al., 2021). This study focuses on an evidence-based
approach to providing a nurse-led case management program. Building on a similar approach to
the acute care intervention program at Johns Hopkins (Berkowitz et al., 2018), the XXXXX
emergency department will deploy a similar model of post-discharge care to patients. The Bridge
program seeks to bridge the gap between hospital resources and patient follow-up care following
discharge.
RESEARCH QUESTION AND DESIGN 4
Objectives
The Bridge program will focus on 1) early screening; 2) multi-disciplinary care
coordination; 3) enhanced patient education; 4) medication management assistance; 5) telephone
follow-up by nursing to coordinate post-discharge care management; and 6) 24/7 access to nurse
call line to triage the need for emergency department care or assistance in accessing alternative
resources. The question this research project seeks to answer is: What effect does the XXXXXX
Bridge program have on the number of unreimbursed healthcare costs for the facility? The author
hypothesizes that enrolling adult patients with chronic health conditions, presenting to the
XXXX emergency department more than 9 times in a rolling 12-month period in the Bridge
program for comprehensive case management, will decrease the number of unreimbursed dollars
to the organization.
Design
Evidence-based practice requires research to enhance patient care and empowers nurses
and patients to make informed decisions regarding their care. This improves the quality of
healthcare provided to patients. Since convenience sampling will be used to enroll participants in
the study, the study will be quasi-experimental in design. In quasi-experimental research, there
are two variables, independent and dependent (Gray & Grove, 2020). Implementing the Bridge
program in the experimental group is the independent variable in this study. Identifying
independent variables is intentional on the researcher’s part and requires the researcher to control
their effect on the dependent variable. Research participants are not randomly assigned in this
case. The dependent variable is the outcome to be measured after the intervention is applied to
the independent variable. This allows the researcher to determine the effect that results from the
RESEARCH QUESTION AND DESIGN 5
intervention on the independent variable (Gray & Grove, 2020). In this study, the dependent
variable will be the number of unreimbursed dollars to the healthcare organization.
Conclusion
Emergency departments seek to provide high-quality care to all their patients. High-need,
high-cost users of the emergency department drain both physical and financial resources,
decreasing the ability of clinical staff to provide effective, high-quality care consistently (Hsuan
et al., 2022). Innovative approaches are often sought to meet the increasing demands placed on
clinical staff in emergency departments and meet the changing needs of the communities they
serve. The XXXXX emergency department seeks to provide compassionate care to its clientele
and make a positive difference in their lives (King James Bible, 1769/2024, Jude 22). The Bridge
program seeks to provide an innovative solution to the organization's growing problem of
unreimbursed healthcare costs. This study seeks to determine if this program will be a wise
allocation of resources by providing a comprehensive, nurse-led case management program. An
effective program will identify patients needing these additional resources, provide the resources,
and, in turn, see a decrease in the number of unreimbursed healthcare costs to the XXXX
organization.
RESEARCH QUESTION AND DESIGN 6
References
Berkman, N. D., Chang, E., Seibert, J., Ali, R., Porterfield, D., Jiang, L., Wines, R., Rains, C., &
Viswanathan, M. (2021). Management of high-need, high-cost patients: A "best fit"
framework synthesis, realist review, and systematic review (AHRQ Publication No.
21(22)-EHC028). Agency for Healthcare Research and Quality.
https://effectivehealthcare.ahrq.gov/products/high-utilizers-health-care/research
Berkowitz, S. A., Parashuram, S., Rowan, K., Andon, L., Bass, E. B., Bellantoni, M., Brotman,
D. J., Deutschendorf, A., Dunbar, L., Durso, S. C., Everett, A., Giuriceo, K. D., Hebert,
L., Hickman, D., Hough, D. E., Howell, E. E., Huang, X., Lepley, D., Leung,
C.,...Brown, P. C. (2018). Association of a care coordination model with health care costs
and utilization. JAMA Network Open, 1(7), e184273.
https://doi.org/10.1001/jamanetworkopen.2018.4273
Bilazarian, A., Hovsepian, V., Kueakomoldej, S., & Poghosyan, L. (2021). A systematic review
of primary care and payment models on emergency department use in patients classified
as high need, high cost. Journal of Emergency Nursing, 47(5), 761–777.e3.
https://doi.org/10.1016/j.jen.2021.01.012
Chang, E. T., Asch, S. M., Eng, J., Gutierrez, F., Denietolis, A., & Atkins, D. (2021). What is the
return on investment of caring for complex high-need, high-cost patients? Journal of
General Internal Medicine, 36(11), 3541–3544. https://doi.org/10.1007/s11606-021-
07110-y
Gonçalves, S., von Hafe, F., Martins, F., Menino, C., Guimarães, M., Mesquita, A., Sampaio, S.,
& Londral, A. (2022). Case management intervention of high users of the emergency
RESEARCH QUESTION AND DESIGN 7
department of a Portuguese hospital: A before-after design analysis. BMC Emergency
Medicine, 22(1). https://doi.org/10.1186/s12873-022-00716-3
Gray, J. R., & Grove, S. K. (2020). Burns and Grove's the practice of nursing research:
Appraisal, synthesis, and generation of evidence (9th ed.). Elsevier.
Hastings, S. N., Stechuchak, K. M., Coffman, C. J., Mahanna, E. P., Weinberger, M., Van
Houtven, C. H., Schmader, K. E., Hendrix, C. C., Kessler, C., Hughes, J. M., Ramos, K.,
Wieland, G., Weiner, M., Robinson, K., & Oddone, E. (2019). Discharge information and
support for patients discharged from the emergency department: Results from a
randomized controlled trial. Journal of General Internal Medicine, 35(1), 79–86.
https://doi.org/10.1007/s11606-019-05319-6
Hsuan, C., Segel, J. E., Hsia, R. Y., Wang, Y., & Rogowski, J. (2022). Association of emergency
department crowding with inpatient outcomes. Health Services Research, 58(4), 828–
843. https://doi.org/10.1111/1475-6773.14076
King James Bible. (2024). King James Bible Online. https://www.kingjamesbibleonline.org/
(Original work published 1769)
Shrapnel, S., Dent, E., & Nicholson, C. (2019). A nurse-led model of care within an emergency
department reduces representation rates for frail aged care residents. Aging Clinical and
Experimental Research, 31(11), 1695–1698. https://doi.org/10.1007/s40520-018-1101-z
Zodda, D., & Underwood, J. (2019). Improving emergency department throughput: Evidence-
based strategies aimed at reducing boarding and overcrowding. Physician Leadership
Journal, 6(3), 70–74. https://go.gale.com/ps/i.do?p=GBIB&u=vic_liberty&id=GALE|
A586903711&v=2.1&it=r&sid=summon
