Amid reports of rising ER visits, safety nets put focus on primary care

A key goal of health reform is for newly insured individuals to seek out primary care, instead of simply showing up at the emergency room for their health care.

Yet that hasn’t been the case in many emergency departments nationwide, with some reporting even more patients under reform. Earlier this month, an analysis by The Los Angeles Times found that many local hospitals were experiencing increases in ER visits. The article includes a possible explanation for the uptick from Shannon McConville, a health policy researcher at the Public Policy Institute of California:

Researcher McConville said there's no guarantee that expanding health coverage will bring down ER visits. The rates of ER use have been rising for several years, she said, in part because more doctors refer patients to emergency departments to ensure they get quick care or are admitted to the hospital. And for many patients, the emergency room seems like the easiest way to get treatment without an appointment or referral. 'It's sort of a one-stop shop,' she said.

So what can health systems do to direct patients to the most appropriate care instead of the easiest – and more expensive – option of heading to the ER for non-emergency care?

I asked Alice Chen, the chief medical officer for the San Francisco Health Network, the Department of Public Health’s integrated health care system, to share her thoughts on connecting patients to the most appropriate care.

Educating newly insured patients on their primary care options and making sure those options are easily accessible is a challenge. But San Francisco is in “a unique position” thanks to the steps the city put in place before health reform, Chen said.   

She pointed to efforts such as the Healthy San Francisco program, which set up a strong network of primar­­y care clinics for uninsured and underinsured throughout the city. San Francisco now has about 20 community-based clinics where people can access primary care.

“We had a seven-year lead to have people exposed to the idea that primary care is really where you want to be,” she said.

There’s still a lot more work to be done, though.  

The SF Health Network has tried several approaches to encourage patients to access primary care instead of the emergency department. One is an advice line where patients can call in and talk to a nurse about their care. Physicians are available to discuss more straightforward cases by phone.

An initial analysis of calls showed that the most common conditions – such as coughs, urinary track infections and upper respiratory infections — were consistent with the ones they want to get out of the emergency department and into primary care. Of the more than 1,300 calls analyzed, only 0.4 percent were referred to the emergency room, according to Chen.

The network is also working with primary care clinics to allow for same-day or next-day appointments.  

“In our setting, the main way to encourage people not to go to the ER is to make sure there’s timely, easy access to non-ER care,” she said. “There’s definitely an educational component but you need to establish services first.”

Also in the works is a program Chen calls a “reverse referral system.” San Francisco Health Network already uses eReferral, an electronic referral system that connects general practitioners and specialists so they can seamlessly discuss a patient’s care from the primary care setting. The idea behind the “reverse referral” is that patients who end up seeing a specialist via the emergency room or urgent care can be connected with a primary care doctor who will further manage their care – and hopefully keep the patient out of the ER.

The network’s eligibility and finance staff would screen a patient’s record first and determine their eligibility for care to avoid unexpected bills down the road. If a person is eligible, they would pass information to the scheduling department personnel, who would find them an appropriate primary care provider.

Chen acknowledged that San Francisco’s model is distinct and financial incentives to move people out of the ER and into primary care aren’t always aligned: “That’s the real conundrum of American healthcare: Trying to align people’s incentives to do more coordination of care.”

As for other innovative approaches to moving people out of the ER and into primary care, Chen pointed to Alameda County’s “firehouse clinics.” Under this plan, fire stations will have on staff a nurse practitioner who provides primary care and targets those who are uninsured or underinsured. (This article explains the role of this new endeavor in the city of Hayward, which broke ground on a firehouse clinic last summer.)

Chen said all these approaches strive to achieve the same goal: Helping people access the most appropriate care.

“The more difficult and arcane it is for people to access care in the right setting, the more likely they are going to end up in the [emergency department] – one of the only areas where you have a right to healthcare,” Chen said. “No one says you have a right to primary care. That’s why people end up in the ED. Our goal is to make the right path the path of least resistance.”

Photo by NEC Corp. of America via Flickr.

Update: This post has been updated to include additional information on SF Health Network's call-in patients.