title: Reducing utilization by uninsured frequent users of the emergency department: combining case management and drop-in group medical appointments.
abstract: BACKGROUND
  Patients with complex behavioral health and medical problems can have a disproportionate impact on emergency departments.
  
  
  METHODS
  We identified a cohort of 255 low-income, uninsured patients who had used inpatient or emergency department services more than 6 times in the previous 12 months. Between July 2010 and June 2011 we enrolled 36 of these high-risk patients to participate in a twice-weekly drop-in group medical appointment staffed by an interdisciplinary team of a family physician, behavioral health professional, and nurse case manager. The team provided 705 patient visits in a group setting (a total of 108 group sessions) and 652 case manager phone calls. The average number of clients per drop-in group medical appointment was 6.5.
  
  
  RESULTS
  Emergency department use dropped from a rate of 0.58 per patient per month to 0.23 (P < .001), and hospital charges dropped from $1167 per patient per month to $230 (P < .001). Employment status increased from 4 to 14 among the 36 patients enrolled. Total annualized cost of the program was $66,000.
  
  
  CONCLUSIONS
  Team-based drop-in group medical appointments coupled with case management seem to be a cost-effective model to reduce emergency department visits by some patients with complex behavioral health and medical needs.
authors.affiliation: Division of Family Medicine, Mountain Area Health Education Center, Hendersonville, NC 28791, USA. steve.crane@pardeehospital.org
authors.forename: Steven
authors.initials: S
authors.lastname: Crane
authors.forename: Lori
authors.initials: L
authors.lastname: Collins
authors.forename: James
authors.initials: J
authors.lastname: Hall
authors.forename: Donald
authors.initials: D
authors.lastname: Rochester
authors.forename: Steven
authors.initials: S
authors.lastname: Patch
mesh_terms: D000328:Adult; D000553:Ambulatory Care / Q000458:organization & administration* / Q000706:statistics & numerical data*; D001071:Appointments and Schedules; D019090:Case Management / Q000458:organization & administration*; D015897:Comorbidity; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D004651:Employment / Q000706:statistics & numerical data; D005260:Female; D005500:Follow-Up Studies; D006126:Group Processes; D006300:Health Services Misuse / Q000706:statistics & numerical data*; D017722:Hospital Charges / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D017057:Medically Uninsured / Q000706:statistics & numerical data*; D008605:Mental Health Services / Q000458:organization & administration; D009657:North Carolina; D009722:Nurse Practitioners; D010348:Patient Care Team / Q000458:organization & administration*; D011320:Primary Health Care / Q000458:organization & administration* / Q000706:statistics & numerical data; D017664:Uncompensated Care; D014600:Utilization Review