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April 23, 2015/Nursing/Clinical Nursing

Creating Care Plans for Frequent Visitors to the ED

Goal is to improve care, reduce visits and admissions


Hospitals struggle with frequent users and super-utilizers—those patients who show up at the Emergency Department repeatedly, usually complaining of the same ailments. Last fall, Cleveland Clinic’s Fairview Hospital developed a plan to better care for those patients and to alleviate the potential drain on resources associated with recurring visits.


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“We identified patients who were high utilizers of resources, most with underlying stressors in conjunction with medical conditions,” says Barbara Wojtala, MBA, BSN, CPHQ, Director of Care Coordination at Fairview Hospital, a 488-bed regional hospital west of Cleveland. “Because many of them do not have continuity in care, we developed care plans that could easily be followed by any provider.”

Identifying regular visitors to the ED

Fairview Hospital formed the Individualized Plan of Care Committee to address issues surrounding frequent visitors to the ED. The multidisciplinary committee includes nurses and physicians from the ED, spiritual services, pain management, social work, case management, the ombudsman and an ethicist. “We want to treat all of our patients with respect and compassion,” says Wojtala. “And we didn’t want to miss anything, so we created a mechanism that promotes multidisciplinary cooperation to address medical and psycho-social issues.”

The first step taken by the committee was to generate a list of patients who visited the hospital most often between January and October 2014. “I checked how many times certain individuals – and we know the names by heart – use our resources,” says Wojtala. “Some people had been 30, 35, 61 times.” The committee, which meets weekly, selects one patient from the list each meeting and creates an individual care plan for that person.

“As a nurse, you don’t want to become desensitized to these patients,” says Michelle Dudas, MSN, RN, Nurse Manager of the ED at Fairview Hospital. “When they come in with the same complaint – come in 30 times with chest pain and it’s been nothing – the last thing we want to do is assume it’s nothing.” But the ED staff also doesn’t want to order tests such as X-rays and CT scans that may already have been done recently. That’s where the individual care plan comes into play

A care plan for each high-frequency patient

The committee uses a template to create a profile and plan for high utilizers at Fairview Hospital. The template helps them ascertain why the patient comes into the hospital, what the underlying medical and psycho-social issues are and what plan of care needs to be put in place. The template includes:

  • The implementation date
  • Reasons why the committee has selected this patient for an individual care plan, including frequent ED visits, poor compliance and comorbidities
  • Common complaints
  • Prior evaluations
  • Committee recommendations, such as “immediately involve social worker upon arrival”
  • Community and social services they plan to involve, such as visiting nurses or mental health services
  • Name and contact information for the primary care provider, if applicable

The template is placed in the patient’s electronic medical record.

As of January 2015, the committee had created individual care plans for more than a dozen patients. The hospital is holding off on formal education around the program until it has plans for a larger group of patients. However, Dudas has discussed the care plans in staff meetings with ED nurses. “I made it very clear this is not a black list,” she says. “Instead, it helps us better care for our patients and send them to the right resources.”

Dudas says the nurses have praised the individual care plans because it “keeps everybody on the same page.” For example, a nurse who works the night shift three days a week can see what her day shift peers, inpatient nurses, social workers and others have done for the patients. “There’s a consistent message carried out by multiple providers, and that reinforces appropriate care for the patient,” says Dudas.


Early results look promising

Although the program has been in place less than six months, Wojtala says early indications look good. One patient has had fewer placements in an observation bed. Another has visited the ED less often and has had fewer admissions. A group of three patients that often travel in a pack, who the hospital suspects are drug seeking, have not returned to Fairview since their individual care plans were implemented.

“Healthcare is a complex system,” says Dudas. “One of the greatest benefits of this project has been getting the multidisciplinary team together and really looking at every aspect of how we can help these patients.” Sometimes that means lining up a visiting nurse or finding the patient a primary care provider. Other times that requires connecting them with appropriate social or behavioral health services. In every case, the goal is to help patients make informed decisions about the best plan of care for them.

“It takes an entire team working together to develop the plan rather than a siloed approach where there’s a medical plan, a nursing plan, a pharmaceutical plan and a therapy plan,” says Wojtala. “We all work together to identify the needs of high utilizers, document those needs and abide by that plan.


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