Improving Care Transitions to Reduce Avoidable Emergency Department Use
In this interview, Hamad Husainy, DO, FACEP, chief medical officer at PointClickCare, discusses the factors contributing to emergency department utilization, gaps in care transitions between hospitals and skilled nursing facilities, and opportunities for health systems and managed care stakeholders to improve data sharing, reduce preventable readmissions, and support more coordinated care.
Key Takeaways:
- Emergency department (ED) use among older adults is influenced by an aging population and the accessibility and convenience of emergency care.
- Incomplete information and poor communication during transitions between EDs and skilled nursing facilities (SNFs) can contribute to delayed care, avoidable complications, and repeat visits.
- Real-time data sharing, artificial intelligence (AI)-based risk scoring, and stronger coordination among providers, payers, and health systems may help reduce preventable readmissions and improve care transitions.
Please share your name, your title, and a brief overview of your professional history.
Hamad Husainy, DO, FACEP: My name is Hamad Husainy, and I'm an ER doctor from Florence, Alabama. I was raised in Florida and didn't think I wanted to be a doctor. However, my father is a neurologist, and I have 3 siblings who are physicians, so it was sort of destined for me. Finally, after my father stopped coercing me, I came to the decision on my own that I wanted to be a physician. Throughout medical school, I realized that I was much more interested in the macroeconomic and macrospective, so to speak, picture of medicine rather than just the patient-physician relationship. That has stayed with me throughout my early career.
I served in several leadership positions and even started my own firm to recruit and staff EDs with physicians in the mid-2010s. Somewhere around late 2019, I had this epiphany that I needed to learn and really understand the economics of the payer side better. So, I served in leadership roles with some small regional and, ultimately, national payers for about 4 years prior to joining PointClickCare. Why am I here, and what am I doing today? I'm really just trying to solve big problems within the health care landscape between post-acute and acute care.
From your perspective as an emergency physician and chief medical officer, what factors are driving increased emergency department use among older adults and uninsured patients?
Dr Husainy: One factor is the aging population. I heard a very interesting statistic recently: In 1947, there were 700 000 more births than there were in 1946, and in 1948, there were 700 000 more births than there were in 1947. My mother was born in 1947, which makes her 79 years old this year. The reality is that the population is getting older. We're at a time when the birth rate is at an all-time low in the US since it has been measured. So as our population ages, we're going to see more and more people going to the emergency department.
Whether we talk about older adults or uninsured patients, there's also something to be said about the emergency department. It's really the only one-stop shop. We've become a culture that wants more and more answers now—without red tape or barriers to get what we want. The rest of the health care system hasn't really kept up with the convenience of emergency medicine. The convenience of going to a place that can give you answers before you leave is what's leading to a lot of emergency department use, especially among older adults.
When a patient is transferred between an emergency department and a skilled nursing facility, what information gaps are most likely to contribute to delayed care, avoidable complications, or repeat emergency visits?
Dr Husainy: We have to go back and ask ourselves: Why are patients in a post-acute care facility or a SNF? The answer is because they're not well enough to go home. Part of not being well enough to go home is that they need to be monitored. They need to be attended to. They need to get therapy. They need more intense scrutiny of what's good and what's bad. If the whole purpose of sending someone to a SNF is to increase and amp up care compared with what they would receive at home, the reality is that we should be a lot more vigilant. We should have the ability not just to predict, but to react more swiftly.
When it comes to delayed care, if they're in a skilled nursing facility, how are we receiving information about those patients in real time? Are we getting up-to-date lab values? Are we able to synthesize the entire picture and recognize when somebody might be decompensating or having an urgent or emergent issue? That's what leads to delayed care. When we talk about avoidable complications, oftentimes these folks have a lot of chronic health problems. Some of them are new. Some of them are old. Some of them are recurring. Some of them are just an acute exacerbation. Do they have low sodium? Do they have a significant history of heart failure or chronic obstructive pulmonary disease (COPD)? If we don't have a great understanding of what they present with, as well as their perspective on care and whether they have advance care measures in place, that's unfortunately going to cause us to admit more patients than necessary. And when that happens, we know that admission to the hospital increases morbidity and mortality. So, that's the second part of avoiding complications.
And the last thing is repeat emergency visits. The more I see this—whether we're talking about the post-acute population, the senior population, or any population—it really comes down to communication. When I see a patient the first time, if they follow up with their primary care doctor or a SNFist comes to see that patient the next day and is able to get a synopsis of what we did in the ED and understand that their role is to pick up the care of that patient upon return, we would have a lot fewer repeat ED visits. It's not just that direction. It's also the other direction. When patients are sent from a SNF, in this example, back to the ED, we need to understand what care was given up to that point and what is needed going forward. That's really where the breakdown often occurs, causing repeat emergency visits.
What operational or technology changes can health systems and SNFs implement to improve care transitions and reduce preventable readmissions?
Dr Husainy: I'll answer this question backwards. The first thing it comes down to is education, getting everyone to understand that we all want to reduce preventable readmissions. One could argue that this is ubiquitous across our entire nation, where patients are just getting readmitted unnecessarily. It's not because of ill intent. It's because of bad information. It's because of bad handoffs and bad transitions.
So, how do we improve care and transitions? It starts with being able to communicate effectively between locations. Point A to point B—it's that telephone. We're an ever-changing society, especially technology-driven and AI-driven. So how can we take all the information that's necessary and create a document or synopsis of what's most important? We're getting to the point where we should be able to make sure that this synopsis is being sent to the right person at the right time and even potentially tailored for different people within the health care continuum. So being able to synthesize and provide a summary of the post-acute stay when patients transition to the ED—and also when those patients transition as an inpatient back to a SNF—means providing their care team with the most robust but also succinct data necessary to continue care for that patient.
How can organizations use AI-based risk scoring to identify patients who may benefit from early intervention without increasing alert fatigue or clinical burden?
Dr Husainy: The interesting thing about AI-based risk scoring is that it should be there to help us. But like anything, if we create a system that says there's a problem all the time, it's really not that useful. On the flip side, if it says there's never a problem, it's also not that useful. So utilizing research to bring validity to scoring systems is important. Then being able to apply those to AI models to create a number or scoring system that allows us to determine who has the highest risk is really important. It allows for a more objective vs subjective view of a patient.
There are individuals who can potentially monitor the overall condition of patients remotely or at scale in a way that we really couldn't before. These systems are dynamic. They're always changing. Again, it should be a system that's created to bring awareness to maybe the top 10% or 15%. But if it's alerting clinicians and nursing staff about 91% of their patients, for example, it's really of little use and probably creates more noise than help.
With avoidable complications and readmissions estimated at $25 to $45 billion a year, that's clearly a system-level problem, but most hospital execs can't fix everything at once. What roles should health plans, accountable care organizations, and other managed care stakeholders play in supporting better data sharing and reducing avoidable emergency department use?
Dr Husainy: This is a huge problem, and it's not single-threaded. It's not the hospital's fault or the payer's fault or the patient's fault or anything like that. It's just the inevitable outcome of where we're at today. But I don't think that means we should give up. It means there's a lot of room for improvement. Real-time data sharing is super important. We take that responsibility very seriously here at PointClickCare. As the system of record for more than 80% of SNFs in the US, that information is not just for use inside the 4 walls of our SNF partners. We need to take that data and be able to share it with payers, providers, health systems, ambulatory clinics, community services, and others.
Conversely, payers can do the same, right? Working off claims data is great but being able to have real-time visibility into where your patients are, who's treating them, what their diagnoses are, and what interventions are necessary is also important. There's an opportunity to work with EHR partners to share a common point of view on how to reduce readmissions.
And then working with our health system partners and creating alignment—whether it's value-based care or some other payer-care alignment—allows everybody to “win” when patients are sent back home and not readmitted unnecessarily.
I want to make sure I'm very clear in saying this: When patients need to be admitted, when they have an acute emergency, or when they have a need that cannot be cared for elsewhere, they need to be readmitted. So, I'm not saying that we would eliminate all of this, but there's a significant and healthy portion that we can really cut into from this large cost that's hampering our health care system and the economics of our health care system.
