According to the Annals of Emergency Medicine, frequent ED users make up less than 10% of all emergency patients, but they account for about a quarter of all visits. Grady Health System in Atlanta started the Chronic Care Clinic program to connect frequent ED patients with preventive care services using Epic population health tools. Since the program’s inception, ED visits have dropped by nearly 50% in the target population.
Using Healthy Planet in Epic, Grady tracks a pool of high-risk patients, many of whom are experiencing homelessness and unemployment or dealing with chronic conditions. Patients are assigned a care team including advanced practice providers, clinical pharmacists, behavioral health specialists, and community health workers, who work together to create a care plan. Regular support keeps patients on track with routine preventive care appointments, medication regimens, and more.
The Chronic Care Clinic goes beyond just patients’ physical health with an integrated approach that offers patients support in other areas. Community health workers guide patients through the process of getting an ID, applying for housing, and applying for a job. Grady also offers addiction treatment through a partnership with St. Jude’s Recovery Center. “We’ve seen better-than-expected results,” said Leslie Marshburn, Grady’s director of population health.
Read more about Grady’s program from WABE, NPR’s Atlanta affiliate.