Call Me a Doctor

Published on June 11, 2020

A badly cut hand… a child’s piercing earache in the middle of the night… a car accident that leaves someone fighting for life… hospital emergency departments (EDs) are indispensable resources for treating injuries and sudden illnesses. There are times when the nearby ED may be the best or only option.

EDs, however, are healthcare’s most expensive care setting. Even so, they are often crowded with patients who could receive treatment through a primary or urgent care visit. A UnitedHealth Group study determined that two-thirds of privately insured ED visits are avoidable, costing the healthcare system $32 billion a year. To reduce the burden on clinical and administrative resources while improving care quality, health systems must understand the needs and drivers of their most frequent ED visitors.

Who exactly are these “ED super-utilizers” – and what insights can we uncover when we look at their underlying social determinants of health? To find out, we analyzed a comprehensive data set that consisted of consumer and health system encounter information for every adult in the state of Colorado.

Our first step was to define ED super-utilizers as patients who had visited Colorado hospital EDs more than four times over a 24-month period, from January 2017 to December 2018. They represented around 2% of the total population. The map below shows the concentration of ED super-utilizers, by county (blue = lower concentration, orange = higher concentration):

ED Super-Utilizer Concentration by County, Colorado

Source: Carrot Health

Next, we scored each individual in Colorado with the Carrot Social Risk Grouper (SRG), which predicts the risk of adverse health outcomes due to social determinants of health, such as access to food and housing security. The higher a person’s Carrot SRG score, the greater their overall SDoH risk profile.

The link between SDoH risk and ED super-utilizers was clear. As the plot below shows, every one-unit increase in the Carrot SRG score corresponded to a 6.2% increase in the ED super-utilizer rate. This is not surprising. Social barriers to health are highly prevalent among people with a variety of chronic health conditions, such as obesity, high blood pressure, depression and COPD. In addition, chronically ill people with high Carrot SRG scores often lack access to the kind of preventive or primary care that would make their conditions more manageable and help them avoid the ED.

Average SRG Score and ED Super-Utilizers by County, Colorado

Source: Carrot Health

Digging deeper, we also identified which underlying SRG factors impacted ED super-utilizers most. As the chart below shows, the top three factors are:

  • Food insecurity (the inability to pay for or access healthy food);
  • Low socio-economic status (the level of financial volatility in an individual’s life due to bankruptcy or high debt), and
  • Housing instability (the lack of reliable housing or the presence of health hazards such as lead paint, mold, inadequate cooling or heating and radon).

Carrot Social Risk Grouper (SRG) Correlations to ED Super-Utilization

Source: Carrot Health

We also noted differences in the impact of SDoH risk according to age and gender: women between the ages of 15 to 44 were more affected than men.

As value-based care becomes the norm, health systems will be increasingly at risk for the health status of their patient populations. Identifying the unique SDoH needs of individual consumers and populations, using tools such as Carrot SRG scores, allows health systems to deliver care further upstream – reducing the need for higher-cost interventions such as ED visits. This proactive approach will also promote better long-term health outcomes. Here are some steps healthcare providers and payers can take to turn data insights into effective action:

  1. Assess Current Efforts. Do existing programs, policies and interventions hit the mark when it comes to addressing the most important social barriers to health? If not, where are the gaps and where should more resources be directed?
  2. Review Best Practices. What does the research say works best? Reviewing the literature or assessing best practices can help a health plan determine more appropriate interventions, standards or approaches.
  3. Start Simple. Action can be taken without scrapping existing programs or launching new ones. For example, changing the script for front line administrators and triage nurses can surface relevant needs. Similarly, understanding how community resources line up with the most relevant social barriers can help care managers direct patients to effective services.

ED super-utilizers represent low-hanging fruit. Identifying and addressing their social barriers reduces care costs quickly while alleviating the burden on a hospital’s front door and steering needy patients to the most appropriate care setting.

No one wants to visit a hospital ED if they can avoid it. Health systems can make sure that’s easier for patients who need help the most.

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