Reducing Utilization by Uninsured Frequent Users of the Emergency Department: Combining Case Management and Drop-in Group Medical Appointments

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.