Lifeline for Emergency's Frequent Flyers
Mentally ill and poor people who frequently show up at hospital emergency departments are more likely to find good housing and access community services if the hospital implements a multidisciplinary care management system, a new study has found.
The study, conducted by a team from St Vincent's Health in Melbourne, is published in the current issue of the Medical Journal of Australia.
Frequent attendees to the emergency department (ED) are characterised by a mix of poverty, homelessness, psychiatric illness, drug and alcohol use, and chronic medical conditions.
This demographic is often viewed as difficult to engage in long-term care, putting them at higher risk of illness and death, and often attempts have been made to divert frequent ED attendees to other health facilities.
Dr Georgina Phillips, co-author of the study, says previously neither education nor management care plans have altered this state of affairs.
However, the four-year study revealed that multidisciplinary case management appeared to have a positive effect on some psychosocial factors for frequent attendees.
Admissions for overnight observation increased, and there were improvements in the patients' housing stability, the likelihood of establishing regular contact with a GP, and in the patients' access to community services.
"EDs are among the most appropriate places for this population to access acute medical care, offering 24 hour services without exclusion criteria, no monetary charge, and a safe environment with high levels of medical, nursing and allied health resources," Dr Phillips said.
Despite the positive developments, implementing multi-disciplinary case management often resulted in the patient coming even more frequently to the hospital ED.
But Dr Phillips said the increased demand was offset by the benefits to the patients.
"From an emergency demand reduction perspective, case management appears to have the opposite of the desired effect," she said.
"But since attempted diversion has no proven patient benefit, EDs should be wary of assumptions about inappropriate or unnecessary use of ED services.
"EDs are well placed for delivery of care to vulnerable and complex patients, and should be resourced to facilitate this."
In his editorial review of the research, in the same issue of the Medical Journal of Australia, Dr Gordian Fulde, Director of the ED at St Vincent's Hospital in Sydney, said frequent users of hospital EDs can often be seen as time-consuming and "illegitimate" users of resources.
"Some of the debate about the resourcing of very expensive 24-hour services, such as stressed emergency departments, focuses on diverting patients away," he said.
"In an ideal world, there would be no debate about allocation of care teams to sick patients, … nor would certain groups of patients only be really visible once they have deteriorated."
Health care planners can underestimate the need for, and effects of, new services, he cautioned.
"This would be easy to imagine when dealing with a marginalised and at times psychosocially challenged group of people," he said.
"Research measuring appropriate outcomes, including accurate assessments of cost, has to be increased to allow resources to be rationally allocated."
The Medical Journal of Australia is a publication of the Australian Medical Association.