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Safety Net Emergency Departments: Creating Safety Valves for Non-Urgent Care

Hospitals Work to Link Non-Urgent Patients to Treatment in More Cost-Effective Settings

News Release
May 7, 2008

Alwyn Cassil (202) 264-3484 or

WASHINGTON, DC—Faced with more patients seeking care for non-emergencies, safety net hospital emergency departments are working to redirect patients to outpatient clinics, community health centers and private physicians, with varied results, according to a study released today by the Center for Studying Health System Change’s (HSC).

Low-income, uninsured and Medicaid patients often turn to emergency departments (EDs) for care because they lack timely access to care in other settings, according to the study. The growing reluctance of physicians and dentists to serve Medicaid and uninsured patients, along with shortages of primary care physicians and certain specialists, such as psychiatrists, in some communities make obtaining clinic or physician appointments increasingly difficult.

Many safety net hospitals-the public and not-for-profit hospitals serving large proportions of low-income, uninsured and Medicaid patients-have primary and specialty care clinics that are key sources of care for low-income people, yet waits for appointments can be several months.

"While emergency departments provide important access for people who don’t need immediate care but who can’t access a community provider in a timely manner, emergency departments are very expensive settings and are not designed to treat ongoing, chronic needs," said Paul B. Ginsburg, Ph.D., president of HSC, a nonpartisan policy research organization funded in part by the Robert Wood Johnson Foundation.

"Strategies that help direct patients with non-urgent conditions to other settings could increase access, enhance quality and contain costs if there are community providers willing and able to treat more low-income people," said HSC Health Researcher Laurie E. Felland, M.S., coauthor of the study with HSC Senior Consulting Researcher Robert Hurley, Ph.D., and HSC Health Research Analyst Nicole Kemper, M.P.H.

The study’s findings are detailed in a new HSC Issue Brief—Safety Net Hospital Emergency Departments: Creating Safety Valves for Non-Urgent Care—available here. The study is based on HSC’s 2007 site visits to 12 nationally representative metropolitan communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y. HSC has been tracking change in these markets since 1996.

Other key study findings include:

  • Some safety net hospitals are expanding emergency departments to accommodate more patients overall and attract more well-insured patients, but this is a costly response to caring for patients with non-urgent needs.
  • Some hospitals are trying to provide non-urgent care more efficiently-for example using a "fast-track" approach where mid-level practitioners provide care in a setting separate from the ED-but such strategies may attract even more non-urgent patients.
  • Rather than attempting to serve more non-urgent patients, many safety net EDs are attempting to help patients establish "medical homes" that provide preventive and primary care for both episodic medical needs and chronic conditions. Such providers, which include hospital outpatient clinics, community health centers and individual primary care practitioners, may provide less costly care, reduce reliance on the ED for non-urgent conditions and diminish the likelihood of a non-urgent problem going untreated and becoming more severe.
  • · To encourage the use of outpatient clinics and community health centers, some EDs-after screening patients as required by federal law-help patients with non-urgent conditions identify other providers and schedule appointments. A Miami ED added a nurse practitioner to determine which patients could be treated in a clinic and administrative staff to schedule appointments with primary care or dental clinics. Over the course of 18 months, ED staff referred an average of 50 patients a day to clinics-almost double what they initially expected and approximately 15 percent of total ED volume.
  • Another approach used in some communities is to dedicate ED staff to work with patients prior to arrival-in some cases targeting patients with frequent visits-to direct them to primary care settings for non-urgent needs. A Greenville ED added a nurse to serve as a patient advocate to help patients establish a medical home in the community by linking them to private physicians, free clinics and community health centers for care.
  • Safety net hospitals’ efforts to limit ED use for non-urgent conditions face a number of challenges. The amount of primary care available through clinics and health centers varies by community, and overall demand for care typically exceeds supply. Even as primary care capacity for low-income people has expanded in some communities in recent years, ED directors reported significant waits for appointments at health centers and clinics, particularly for new patients and patients needing specialty care.

The study concludes that a combination of approaches could help stem ED use for non-urgent care, including expansion of community health centers, community clinics and hospital clinics and strategies to improve their accessibility. Alignment of hours of operation and available services among existing providers could increase people’s care options at lower costs. Since transportation is a significant barrier for some, bringing services to low-income neighborhoods through mobile vans and school-based services could improve access in a cost-effective way.

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The Center for Studying Health System Change is a nonpartisan policy research organization committed to providing objective and timely research on the nation’s changing health system to help inform policy makers and contribute to better health care policy. HSC, based in Washington, D.C., is funded principally by the Robert Wood Johnson Foundation and is affiliated with Mathematica Policy Research, Inc.



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