title: Reasons for Frequent Emergency Department Use by Medicaid Enrollees: A Qualitative Study.
abstract: BACKGROUND
  The Affordable Care Act initiated several care coordination programs tailored to reduce emergency department (ED) use for Medicaid-enrolled frequent ED users. It is important to clarify from the patient's perspective why Medicaid enrollees who want to receive care coordination services to improve primary care utilization frequently use the ED.
  
  
  METHODS
  We conducted a qualitative data analysis of patient summary reports obtained from Medicaid enrolled frequent ED users who agreed to participate in a randomized control trial (RCT) evaluating the impact of patient navigation intervention compared with standard of care on ED use and hospital admissions. We defined frequent ED users as those who used the ED four to 18 times in the past year. The study was conducted at an urban, teaching hospital ED with approximately 90,000 visits per year. The research staff conducted interviews (~30-40 minutes), regarding the patient's medical history, reasons for ED visits, health care access issues, and social distresses. The aforementioned findings were summarized in a 1- to 2-page report and presented to the RCT's project team (social worker, emergency medicine physician, primary care physician, and patient navigators) on a weekly basis to further understand the needs of this patient population. A diverse team of researchers (program staff and physicians) coded all reports and reached consensus using reflexive team analysis. We reconciled differences in code interpretations and generated themes.
  
  
  RESULTS
  One-hundred patients enrolled in the RCT from March 2013 to February 2014, and all 100 patient summary reports were evaluated. We identified three key themes associated with Medicaid enrollee frequent ED use: 1) negative personal experiences with the healthcare system, 2) challenges associated with having low socioeconomic status, and 3) significant chronic mental and physical disease burden.
  
  
  CONCLUSIONS
  Medicaid frequent ED users engaged in receiving patient navigation services with the goal to reduce ED use and hospital admissions describe barriers that go beyond timely primary care access issues. These include sociodeterminants of health, lack of trust in primary care providers, and healthcare system.
authors.affiliation: Department of Emergency Medicine, University of Colorado, School of Medicine, Aurora, CO.
authors.forename: Roberta
authors.initials: R
authors.lastname: Capp
authors.affiliation: Project Access-New Haven, New Haven, CT.
authors.forename: Lauren
authors.initials: L
authors.lastname: Kelley
authors.affiliation: Department of Medicine, Yale University School of Medicine, New Haven, CT.
authors.forename: Peter
authors.initials: P
authors.lastname: Ellis
authors.affiliation: Project Access-New Haven, New Haven, CT.
authors.forename: Juan
authors.initials: J
authors.lastname: Carmona
authors.affiliation: Project Access-New Haven, New Haven, CT.
authors.forename: Adrienne
authors.initials: A
authors.lastname: Lofton
authors.affiliation: Project Access-New Haven, New Haven, CT.
authors.forename: Darcey
authors.initials: D
authors.lastname: Cobbs-Lomax
authors.affiliation: Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT.
authors.forename: Gail
authors.initials: G
authors.lastname: D'Onofrio
mesh_terms: D000328:Adult; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006304:Health Status; D006784:Hospitals, Teaching / Q000458:organization & administration; D006786:Hospitals, Urban / Q000458:organization & administration; D006801:Humans; D008297:Male; D008484:Medicaid / Q000706:statistics & numerical data*; D020380:Needs Assessment; D010348:Patient Care Team / Q000458:organization & administration; D062526:Patient Navigation / Q000458:organization & administration*; D036301:Qualitative Research; D064890:Social Determinants of Health; D000068217:Social Workers; D012959:Socioeconomic Factors; D014481:United States