Vox Medicus

"Vox Medicus," is a periodic feature in DOC-Line that provides a showcase for editorials from members of the medical staff. Members of the medical staff are encouraged to submit editorials to Dr. Matt Miller or Dr. Tom Koobatian.

This issue’s voice is Patrick Broderick, MD, FACEP, Chairman Department of Emergency Medicine, and President Western CT Medical Group.

Preparing for the Affordable Care Act: Danbury Hospital's Six Strategies to Manage Increased Emergency Department Volume

Patrick Broderick, MD, FACEP, Chairman Department of Emergency Medicine, and President Western CT Medical Group

Beginning next year, the Patient Protection and Affordable Care Act (Obamacare) will expand insurance coverage to many currently uninsured, which will ultimately result in nearly 30 million newly insured Americans. Emergency departments account for approximately half of hospital admissions, and this means EDs need to be prepared to manage an influx of visitors.

We currently see approximately 70,000 patients a year, and expect this number to increase significantly. We have a six-part plan for preparing to manage increased patient volume. The plan involves physical expansion and several system improvement initiatives that could affect your practice and your patients.

1. Facility expansion. Danbury Hospital plans to increase ED capacity from approximately 20,000 square feet with 40 examination rooms to 40,000 square feet with 69 private exam rooms.

2. Streamlined patient flow. Our ED is changing patient flow to increase our ability to handle more patients faster. We will have a fast track area for patients with less urgent conditions so they can be seen expeditiously. Having separate areas for patients based on the urgency of their condition means patients with minor problems do not have to compete for a bed directly with patients who need immediate, life-saving attention.

The hospital is also shortening the intake process by bringing registration to the bedside. Registration at the bedside eliminates the back-and-forth from triage to the waiting room to registration and back to the waiting room. This allows us to get the patients into the examination room that much sooner so the doctor can see them.

3. Case management. Danbury’s ED is using case management to ensure patients receive care in the most appropriate setting. Guiding patients through care transitions and preventing gaps in care benefits not only the patients who are transitioning, but also other ED patients, because a well-executed transition can prevent the need for a patient to return to the ED shortly after discharge. Fewer unnecessary ED visits means shorter wait times and less crowding.

We staff with one case manager per shift who is responsible for ensuring patients are being sent to the most appropriate setting and coordinating services patients will need after they leave the ED. The case manager may advise whether patients meet criteria for admission to inpatient care or may arrange any necessary home services for patients being discharged to home.

4. Enhanced communication. We will enhance communication between the ED and outside providers, including transferring hospitals and primary care physicians, to ensure patients' transition in and out of the ED is smooth. For example, the ED established a portal to collect information from hospitals, skilled nursing facilities and other providers that are transferring patients to Danbury Hospital. Having this information allows ED staff to prepare for the incoming patient. In addition, the ED notifies the primary care physician as soon as a patient enters the department so the PCP is aware of the patient's situation.

After discharge, the ED communicates with patients' primary care physician or other post-ED care providers so the patient receives the appropriate follow-up care. The ED provides the post-discharge provider, whether a physician, skilled nursing facility or home care provider, with a copy of the patient evaluation, including the results of tests and recommended next steps. Communication during care transitions ensures patients receive the care they need and reduces the likelihood patients will need to return to the ED for the same complaint.

5. Expanded primary care relationships. Danbury Hospital and Western Connecticut Health Network are working to build relationships with more primary care physicians to create capacity for more patients and more easily coordinate patients' transitions between the community and hospital. Western Connecticut Health Network has several models of physician relationships, including employment, a physician-hospital organization and more informal alignment strategies. The health system is working with its employed physicians in Western Connecticut Medical Group and independent physician practices to ensure they can accept referrals from the ED so patients can easily schedule follow-up visits and seek care in the most appropriate setting.

We're making sure we have an adequate supply of primary care practices to be able to refer these patients, once they present to the ER, back to primary care so the next time they have a medical problem, they don't necessarily go to the ER because they have access to a primary care doctor.

6. Growth of non-physician provider relationships. In addition to partnering with primary care physicians, Western Connecticut Health Network and Danbury Hospital are building relationships with federally qualified health centers, non-profit clinics and other providers, such as nurse practitioners and physician assistants, to expand patients' options for care. Leveraging non-physician providers is going to be extremely important in the future so patients are seen by the appropriate provider and have good follow-up so the illness doesn't worsen, requiring them to go back to the ER. Trying to get people connected into the healthcare system, getting them engaged in preventive health and setting up transitions are going to be critical over the next couple years.

Patient-centered medical neighborhood
The hospital's efforts in preparing for an increase in patient visits align with the patient-centered medical home model, in which a team of primary care physicians coordinates care for the patient. Danbury Hospital is working to expand this model to a patient-centered medical neighborhood that has ED physicians, primary care physicians, specialists and other providers. Under this model, providers will communicate with each other to facilitate handoffs and provide patients easy access to the care they need.

At the core is coordinating care across different providers and making sure the patient gets to the appropriate provider to receive care.

We don’t know completely how the Affordable Care Act will affect us, but these are six steps we have chosen. If you or your staff has suggestions that will allow the Emergency Department to better help you and your patients during this transition time, please contact me.

Pat