title: ED diversion: multidisciplinary approach engages high utilizers, helps them better navigate the health care system.
abstract: Working with partners, the St. Charles Health System in Bend, OR, has implemented an ED diversion project that is helping patients who frequent the ED connect with more appropriate settings for their primary care needs. The hospital identifies high ED utilizers using claims data, then a multidisciplinary engagement team establishes care plans for these patients. The most at-risk patients are paired with community health workers to help them better navigate the health care system. The ED diversion project has reduced unnecessary ED utilization by 45% to 70% in cohorts of patients that the hospital has analyzed thus far. The hospital contracts with a non-profit organization to supply and train community health workers. Community health workers follow a structured model that includes more than 80 different pathways to follow, based on patient conditions.
mesh_terms: D003299:Cooperative Behavior; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D006300:Health Services Misuse; D006801:Humans; D033183:Interdisciplinary Communication; D017146:Models, Organizational; D009922:Oregon; D019982:Organizational Case Studies; D011320:Primary Health Care