For patients who frequently visit the emergency department, creating a care plan and connecting them with community resources can help them stay healthy and out of the ED. With outreach to frequent ED visitors and personalized care planning, WellStar reduced ED visits by 46% in their pilot population in three months.
“We had such success by addressing social determinants in our accountable care model that we decided to try a similar care management team approach for our population of patients that use the ED for primary care,” said Kamela Sooknanan, WellStar’s assistant vice president of population health and clinical integration.
WellStar uses data in Epic to identify patients who visit the ED most frequently. A social worker joins these patients’ care teams to help them with things like establishing a primary care provider, arranging transportation to a local food bank, or scheduling a follow-up appointment for preventive care. Reports in Epic help the care team monitor patient trends, such as a need for evening and overnight support.
“We took a chance with investing in this program, and it’s been worth it,” said Sooknanan.