The Use of Patient Narratives to Understand High Emergency Department Utilization Among Medicaid Patients at a Safety-Net Hospital: A Quality Improvement Project

Abstract

Background: National health reform efforts are increasingly focused on the needs of “high utilizer” patients who account for a disproportionate number of emergency room admissions. Complex care teams and other quality improvement efforts are not uniformly successful, and the patients’ voice is often absent from these efforts. Purpose: To implement a quality improvement project at Cambridge Hospital with the goal of (1) directly engaging patients and use Narrative Inquiry methods to better understand the experiences and barriers to health among the highest utilizing patients of the emergency department (ED), in order to identify more patient-centered areas for quality improvement, and (2) understanding primary care providers’ and complex care management providers’ perceptions of utility and feasibility of this approach. Methods: Using Medicaid subsidiary claims data, 41 patients who had four or more visits to the ED in the past year were identified, and 11 patients were able to participate in the study. Patients were interviewed using Narrative Inquiry methodology in order to better understand patients’ experiences with healthcare, reasons for ED utilization, and perceived barriers to healthcare services. Investigators coded transcripts using inductively-derived codes. Patient narratives were summarized and sent to primary care providers (PCPs), and results were disseminated to complex care stakeholders. Feedback on the utility of this was elicited. Results: Eleven of 41 patients were able to be contacted and were available for an interview. Conversations with patients regarding their ED utilization revealed themes of substance use disorder, somatic concerns, and high levels of childhood trauma. Patients with substance use-related concerns reported feeling “forced” to use the ED as they were brought in intoxicated by ambulance and identified a lack of wet shelters and long-term addiction treatment centers as needs. In contrast, patients with somatic concerns identified a high sense of anxiety around their symptoms which triggered their use of the ED versus other healthcare options, as going to the ED helped them to feel reassured. These patients identified intensive care management services and longitudinal mental health providers as needs. Regardless of the reasons for ED use, a majority of these patients reported a significant level of childhood trauma and linked that history to current addiction or anxiety. Results were conveyed to PCPs and complex care team members, but the utility of the results was difficult to ascertain given low response rate. Conclusion: This is a very challenging-to-reach population, with a limited number of patients having the ability to be contacted and participate in an interview. Overall, this project demonstrates a way in which the narrative interview approaches with patients can be integrated into quality improvement efforts focused on patients who are high utilizers of the Emergency Department in order to inform more targeted areas for intervention and better address the unique needs of this heterogeneous population. Responses from patients reveal interacting themes of substance use disorder, somatic concerns, childhood trauma, and social isolation which warrant further exploration using rigorous study designs.