Enhancing Dispositions from the Emergency Department—the Northern California Journey to Care for Increasingly Complex Populations


Rayne Soriano PhD, RN; Vivian Reyes, MD; Jo-Ann Griffin, RN


Abstracts from the Kaiser Permanente 2019 National Quality Conference

From Northern California

Background: Amidst the challenges with overcrowding, Emergency Departments (EDs) across the nation, including Kaiser Permanente’s, are experiencing an increase in utilization from complex patient cases such as the frail and elderly, the homeless, and those with behavioral health conditions. Homeless patients, for example, are 50.8% more likely to be readmitted to hospitals and stay 2.3 days longer, resulting in increased utilization and costs.
Methods: Focusing on complex patient populations, 6 ED engagements were conducted to highlight systemwide opportunities to reduce ED length of stay, ED admission rates, ED visits, ED readmissions, and to improve care for our diverse patient populations, while also defining standard work for all medical centers. As part of the design, a new role—care without delay director—was formed to work during the ED’s busiest times to be a catalyst in enhancing patient dispositions. This work also facilitated the development of a comprehensive Enhanced ED Disposition scorecard to monitor and sustain quality care in the ED.
Results: These engagements generated systemwide enhancements: AllScripts technology in the ED; standard work for leaders and frontline staff; role clarity for the continuum aligned with a “pull strategy” from the ED; and an insight-driven scorecard for ED Care Without Delay performance. Throughout the pilots, we learned qualitative and quantitative outcomes revealing continued opportunities to improve our design and measurement strategy for Enhanced ED Disposition. Feedback from leaders and frontline caregivers have been positive, and as we finalize the design and evaluation of a model for spread, our pilot sites have shown improvements in ED admit rates and ED length of stay. Work plans for local leaders were also developed to sustain a culture of care without delay in the ED.
Discussion: This work raised the awareness for the need of systemwide solutions and a measurement strategy to guide next steps of enhanced ED disposition. The details gleaned from the engagements validated the depth of the challenges of complex dispositions from the ED and provided a new line of sight into ED operations while strengthening partnerships between the ED, rehabilitation medicine or risk management, home-based support, and the continuum to solve problems in real time. These enhancements will be incorporated into the foundational hospital model of care for 2019. The following opportunities were also revealed: Specialized geriatric ED care, homeless pathways, nonmember workflows, and enhancing ED behavioral health.

Abstracts from the Kaiser Permanente 2019 National Quality Conference


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