The effects of clinical case management on hospital service use among ED frequent users

doi:10.1053/ajem.2000.9292

The American Journal of Emergency Medicine

Volume 18, Issue 5, September 2000, Pages 603-608

https://doi.org/10.1053/ajem.2000.9292 Get rights and content

Abstract

This study examined the impact of case management on hospital service use, hospital costs, homelessness, substance abuse, and psychosocial problems in frequent users of a public urban emergency department (ED). Subjects were 53 patients who used the ED five times or more in 12 months. Utilization, cost, and psychosocial variables were compared 12 months before and after the intervention. The median number of ED visits decreased from 15 to 9 (P <.01), median ED costs decreased from $4,124 to $2,195 (P < .01) and median medical inpatient costs decreased from $8,330 to $2,786 (P < .01). Homelessness decreased by 257% (P < .01), alcohol use by −22% (P = .05) and drug use by −26% (P < .05). Linkage to primary care increased 74% (P < .01). Fifty-four percent of medically indigent subjects obtained Medicaid (P .01). There was a net cost savings, with each dollar invested in the program yielding a $1.44 reduction in hospital costs. Thus, case management appears to be a cost-effective means of decreasing acute hospital service use and psychosocial problems among frequent ED users. (Am J Emerg Med 2000;18:603–608.

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2022, eClinicalMedicine
People experiencing homelessness have significant unmet needs and high rates of unplanned care. We aimed to describe preventative interventions, defined in their broadest sense, for people experiencing homelessness in a hospital context. Secondary aims included mapping outcomes and assessing intervention effectiveness.
We searched online databases (MEDLINE, Embase, PsycINFO, HMIC, CINAHL, Web of Science, Cochrane Library) from 1999–2019 and conducted backward and forward citation searches to 31 December 2020 (PROSPERO CRD42019154036). We included quantitative studies in emergency and inpatient settings measuring health or social outcomes for adults experiencing homelessness in high income countries. We assessed rigour using the “Quality Assessment Tool for Quantitative Studies” and summarised findings using descriptive quantitative methods, a binomial test, a Harvest Plot, and narrative synthesis. We used PRISMA and SWiM reporting guidelines.
Twenty-eight studies identified eight intervention types: care coordination (n=18); advocacy, support, and outreach (n=13); social welfare assistance (n=13); discharge planning (n=12); homelessness identification (n=6); psychological therapy and treatment (n=6); infectious disease prevention (n=5); and screening, treatment, and referrals (n=5). The evidence strength was weak (n=16) to moderate (n=10), with two high quality randomised controlled trials. We identified six outcome categories with potential benefits observed for psychosocial outcomes, including housing (11/13 studies, 95%CI=54.6–98.1%, p=0.023), healthcare use (14/17, 56.6–96.2%, p=0.013), and healthcare costs (8/8, 63.1–100%, p=0.008). Benefits were less likely for health outcomes (4/5, 28.3–99.5%, p=0.375), integration with onward care (2/4, 6.8–93.2%, p=1.000), and feasibility/acceptability (5/6, 35.9–99.6%, p=0.219), but confidence intervals were very wide. We observed no harms. Most studies showing potential benefits were multi-component interventions.
Hospital-based preventative interventions for people experiencing homelessness are potentially beneficial, but more rigorous research is needed. In the context of high needs and extreme inequities, policymakers and healthcare providers may consider implementing multi-component preventative interventions.
SL is supported by an NIHR Clinical Doctoral Research Fellowship (ICA-CDRF-2016-02-042). JD is supported by an NIHR School of Public Health Research Pre-doctoral Fellowship (NU-004252). RWA is supported by a Wellcome Clinical Research Career Development Fellowship (206602).
An evaluation of the use of management care plans for people who frequently attend the emergency department
2019, Australasian Emergency Care
Citation Excerpt :
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To evaluate the use of management plans for people who frequently attend the emergency department (ED).
Management plans are used to decrease ED utilisation by people who frequently attend. There is limited evidence regarding the use management plans for this population and the perspectives of staff who use them has previously not been considered.
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The date for commencement of each plan was determined. Data were extracted regarding ED attendance 12 months before and after implementation. Staff perspectives were obtained via an online survey.
Fifty-seven patients made 1482 ED attendances. Of these 830 occurred in the 12 months before the management plan was implemented and 652 during the 12 months after. The number of attendances per patient decreased from a median of 11 to 4. Staff considered management plans to be beneficial to care planning practices and individual patient outcomes.
Management plans were acceptable to staff, and implementation of management plans was associated with a decrease in ED attendance.
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Clinical guideline for homeless and vulnerably housed people, and people with lived homelessness experience
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^☆: Supported in part by a foundation award from the Friends of Langley Porter Neuropsychiatric Institute and the San Francisco Department of Public Health.

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Brief ReportsThe effects of clinical case management on hospital service use among ED frequent users☆

Abstract

Brief Reports
The effects of clinical case management on hospital service use among ED frequent users☆