Working Together to Connect Care: a metropolitan tertiary emergency department and community care programDebra Harcourt A C , Clancy McDonald B , Leonie Cartlidge-Gann A and John Burke B
A Royal Brisbane and Women’s Hospital, Metro North Hospital and Health Service, Patient Flow Unit, James Mayne Building, Butterfield Street, Brisbane, Qld 4006, Australia. Email: firstname.lastname@example.org
B Royal Brisbane and Women’s Hospital, Metro North Hospital and Health Service, Emergency Department, James Mayne Building, Butterfield Street, Brisbane, Qld 4006, Australia. Email: email@example.com; firstname.lastname@example.org
C Corresponding author. Email: email@example.com
Australian Health Review - https://doi.org/10.1071/AH16236
Submitted: 26 October 2016 Accepted: 19 December 2016 Published online: 2 March 2017
Objective Frequent attendance by people to an emergency department (ED) is a global concern. A collaborative partnership between an ED and the primary and community healthcare sectors has the potential to improve care for the person who frequently attends the ED. The aims of the Working Together to Connect Care program are to decrease the number of presentations by providing focused community support and to integrate all healthcare services with the goal of achieving positive, patient-centred and directed outcomes.
Methods A retrospective analysis of ED data for 2014 and 2015 was used to ascertain the characteristics of the potential program cohort. The definition used to identify a ‘frequent attendee’ was more than four presentations to an ED in 1 month. This analysis was used to develop the processes now known as the Working Together to Connect Care program. This program includes participant identification by applying the definition, flagging of potential participants in the ED IT system, case review and referral to community services by ED staff, case conferencing facilitated within the ED and individualised, patient centred case management provided by government and non-government community services.
Results Two months after the date of commencement of the Working Together to Connect Care program there are 31 active participants in the program: 10 are on the Mental Health pathway, and one is on the No Consent pathway. On average there are three people recruited to the program every week. The establishment of a new program for supporting frequent attendees of an ED has had its challenges. Identifying systems that support people in their community has been an early positive outcome of this project.
Conclusion It is expected that data regarding the number of ED presentations, potential fiscal savings and client outcomes will be available in 2017.
What is known about the topic? Frequent attendance at EDs is a global issue and although the number of ‘super users’ is small compared with non-frequent users, the presentations are high. People in the frequent attendee group will often seek care from multiple EDs for, in the main, mental health issues and substance abuse. Furthermore, frequent ED users are vulnerable and experience higher mortality, hospital admissions and out-patient visits than non-frequent users. Aggressive and assertive outreach, intense coordination of services by integrated care teams, and the need for non-medical resources, such as supportive housing, have positive outcomes for this group of people.
What does this paper add? This study uses international research findings in an Australian setting to provide a testing of the generalisability of an assertive and collaborative ED and community case management approach for supporting people who frequent a metropolitan ED.
What are the implications for practitioners? The chronicling of a process undertaken to affect change in a health care setting supports practitioners when developing processes for this cohort across different ED contexts.
References Duckett S, Breadon P, Farmer J. Unlocking skills in hospitals: better jobs, more care. Melbourne: The Grattan Institute. 2014. Available at: http://grattan.edu.au/wp-content/uploads/2014/05/810-unlocking-skills- in-hospitals.pdf [verified 22 January 2017].
 Cameron PA, Thompson DR. Changing the health-care workforce. Int J Nurs Pract 2005; 11 1–4.
| Changing the health-care workforce.CrossRef |
 Kirby SE, Dennis SM, Jayasinghe UW, Harris MF. Frequent emergency attenders: is there a better way? Aust Health Rev 2011; 35 462–7.
| Frequent emergency attenders: is there a better way?CrossRef |
 Vinton DT, Capp R, Rooks SP, Abbott JT, Ginde AA. Frequent users of US emergency departments: characteristics and opportunities for interventions. Emerg Med J 2014; 31 526–32.
| Frequent users of US emergency departments: characteristics and opportunities for interventions.CrossRef |
 O’Cathain A, Knowles E, Maheswaran R, Pearson T, Turner J, Hirst E, Goodacre S, Nicholl J. A system-wide approach to explain variation in potentially avoidable emergency admissions: national ecological study. BMJ Qual Saf 2014; 23 47–55.
| A system-wide approach to explain variation in potentially avoidable emergency admissions: national ecological study.CrossRef |
 McCormack RP, Hoffman LF, Wall SP, Goldfrank LR. Resource-limited collaborative pilot intervention for chronically homeless, alcohol-dependent frequent emergency department users. Am J Public Health 2013; 103(Suppl S2) S221–4.
| Resource-limited collaborative pilot intervention for chronically homeless, alcohol-dependent frequent emergency department users.CrossRef |
 Sadowski LS, Kee RA, VanderWeele TJ, Buchanan D. Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults. A randomized trial. JAMA 2009; 301 1771–8.
| Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults. A randomized trial.CrossRef | 1:CAS:528:DC%2BD1MXls1Wjt78%3D&md5=1405c9345670c2c23d7d08aa1a28ec9bCAS |
 Markham D, Graudins A. Characteristics of frequent emergency department presenters to an Australian emergency medicine network. BMC Emerg Med 2011; 11 16
| Characteristics of frequent emergency department presenters to an Australian emergency medicine network.CrossRef |
 Raven M, Gould D. Time and again: frequent users of emergency departments in New York City. New York: United Hospital Fund. 2012. Available at: https://www.uhfnyc.org/publications/880847 [verified 22 January 2017].
 Liu SW, Nagurney JT, Chang Y, Parry BA, Smulowitz P, Atlas SJ. Frequent ED users: are most visits for mental health, alcohol, and drug-related complaints? Am J Emerg Med 2013; 31 1512–5.
| Frequent ED users: are most visits for mental health, alcohol, and drug-related complaints?CrossRef |
 Purdy S, Huntley A. Predicting and preventing avoidable hospital admissions: a review. J R Coll Physicians Edinb 2013; 43 340–4.
 Wilson A, Baker R, Bankart J, Banerjee J, Bhamra R, Conroy S, Kurtev S, Phelps K, Regen E, Rogers, S, Waring, J. Establishing and implementing best practice to reduce unplanned admissions in those 85 years and over through system change (Establishing System Change for Admissions of People 85+ (ESCAPE 85+)): a mixed-methods case study approach. Health Services and Delivery Research 2015; 3 37
 Smith SM Chambers D Best practice guidelines, frequent attenders in the emergency department. London: The College of Emergency Medicine. 2014. Available at: https://www.rcem.ac.uk/docs/College%20Guidelines/5x.%20Frequent%20Attenders%20in%20the%20Emergency%20Department%28August%202014%29.pdf [verified 22 January 2017].
 Morgan SR, Chang AM, Alqatari M, Pines JM. Non-emergency department (ED) interventions to reduce ED utilization: a systematic review. Acad Emerg Med 2013; 20 969–85.
| Non-emergency department (ED) interventions to reduce ED utilization: a systematic review.CrossRef |
 Soril LJJ, Leggett LE, Lorenzetti DL, Noseworthy TW, Clement FM. Reducing frequent visits to the emergency department: a systematic review of interventions. PLoS One 2015; 10 e0123660
| Reducing frequent visits to the emergency department: a systematic review of interventions.CrossRef |
 Scott J, Strickland P, Warner K, Dawson P. Frequent callers to and users of emergency medical systems: a systematic review. Emerg Med J 2014; 31 684–91.
| Frequent callers to and users of emergency medical systems: a systematic review.CrossRef |
 Homeless Link. Evaluation of the Homeless Hospital Discharge Fund, Department of Health, London SE114AP 2015. Available at: http://www.homeless.org.uk/sites/default/files/site-attachments/Evaluation%20of%20the%20Homeless%20Hospital%20Discharge%20Fund%20FINAL.pdf [verified 22 January 2017].
 Primary Health Care Advisory Group. Better outcomes for people with chronic and complex health conditions. Canberra: Commonwealth of Australia, Department of Health. 2015. Available at: www.health.gov.au/internet/main/publishing.nsf/Content/76B2BDC12AE54540CA257F72001102B9/$File/PHCAG%20Final%20Report.docx [verified 16 May 2016].