Hospital Report Card – Moving to Active: An Aftercare Paradigm Shift in the ED

Project Timeframe: January 2014 – ongoing

Problem: Review of data for patients returning to our ED within 72 hours of their first visit indicated a slow but steady rise. Clinical review of a random sample of all ED patients over a restricted period indicated that approximately 50% of our ED patients could have benefited from outpatient follow-up appointments, such as Primary Care, scheduled lab work or tests, or an appointment with a recommended consultant or specialist.

We knew that follow-up care had been part of the patient’s instructions on discharge form the ED. However, we were also aware that this passive approach to aftercare was resulting in after care failure. It was too easy for the patient to delay until the issue was forgotten, or to simply return to the ED rather than make the effort to contact the care they needed. We were concerned that this only reinforced a slow dis-connection from their Primary Care Physician. This in turn was leading to increased use of the ED for non-emergent care, generating treatment delays and patient dis-satisfaction.

Goal: To schedule appointments for recommended post ED care prior to, or within 24 hours of, the patient’s discharge form the ED.

Interventions: In March, 2014, we put together a multidisciplinary team consisting of the Executive Director of Quality and Care Management, the ED Nurse Manager, a representative from BMH outpatient Physician Practices, a Care Manager and an IT Specialist to address our goal. The team developed the following plan:

  • The ED Physician identifies if a patient could benefit from a follow-up appointment, referral to a specialist or other services.
  • The Physician informs both the patient and the ED Unit Coordinator of the services needed
  • During daytime hours the Unit Coordinator makes appointments or referrals and gives the patient written information regarding those appointments before they leave the ED
  • Evenings and weekends the Unit Coordinator schedules appointments on the next available day and phones the patient with the information
  • Care Managers are available on call to assist with assessing and placing patients in skilled nursing facilities if they meet admission criteria or to arrange home health services for eligible patients.
  • ED Unit Coordinators participated in two training sessions on their role in this new process
  • Each day a Care Manager regularly checks in with the ED regarding any potentially challenging cases or needs, and meets with the team and intervenes as appropriate.

Measures: We are currently gathering data on the number of appointments made and are working with BMH Physician Practices to assess the number of appointments made through this process that have been kept. We also continue to monitor are ED return visits within 72 hours to assess for any indicators of need for process refinement.

Contact Information
Michele Rowland, RN, LICSW
Executive Director, Quality, Utilization and Care Management
Brattleboro Memorial Hospital
17 Belmont Avenue, Brattleboro, VT 05301