Complex Care

Washington University Emergency Medicine Journal Club – August 18th, 2022


It’s another long Saturday night in EM1 when you are sent the last patient in the waiting room. You open up his chart to find a 40-year-old male with PMHx of polysubstance use, severe CHF with EF <15%, and COPD. Today, he is here for leg swelling. You note multiple ED visits and admissions in the last two months for possible CHF exacerbations. His vitals reveal that he is afebrile with BP 175/90, HR 90, RR 15, satting 92% on RA.  He tells you his medications were stolen again at the shelter last week, so he needs a refill and would also like some juice and a turkey sandwich. Also, he tells you he has missed the last several appointments with his cardiologist because he is too short of breath to walk there. He was discharged with similar vitals and a stably elevated BNP last week, and his edema was described as chronic on that discharge summary. You know the medicine team could raise objections if you were to pursue admission. 

We care for complex care patients in the emergency department on a daily basis. Any patient with a decompensated chronic condition with insufficient access to housing, insurance, or primary care can be classified as a complex care patient. In the ED, complex care patients often disproportionately use ED resources and are thus called “frequent utilizers” in the literature, although this term has no clear definition. These patients often have a higher prevalence of multiple comorbid chronic illness—including psychiatric illnesses—lower socioeconomic status, and higher rates of adverse health outcomes. Efforts targeting complex care patients to improve their healthcare access while decreasing avoidable utilization typically involve a multidisciplinary team of physicians and other healthcare staff, such as social workers and case managers, who can connect patients with needed resources.  

This month, we will review key articles in the literature to attempt determine what interventions can be taken to effectively identify complex care patients and reduce ED utilization among patients who are heavy users.

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Article 1: Finkelstein A, Zhou A, Taubman S, Doyle J. Health Care Hotspotting – A Randomized, Controlled Trial. N Engl J Med. 2020 Jan 9;382(2):152-162. doi: 10.1056/NEJMsa1906848. PMID: 31914242; PMCID: PMC7046127.

Article 2: Powers BW, Modarai F, Palakodeti S, Sharma M, Mehta N, Jain SH, Garg V. Impact of complex care management on spending and utilization for high-need, high-cost Medicaid patients. Am J Manag Care. 2020 Feb 1;26(2):e57-e63. doi: 10.37765/ajmc.2020.42402. Erratum in: Am J Manag Care. 2020 Mar;26(3):132. PMID: 32059101.

Article 3: Johnson TL, Rinehart DJ, Durfee J, Brewer D, Batal H, Blum J, Oronce CI, Melinkovich P, Gabow P. For many patients who use large amounts of health care services, the need is intense yet temporary. Health Aff (Millwood). 2015 Aug;34(8):1312-9. doi: 10.1377/hlthaff.2014.1186. PMID: 26240244.

Article 4: Ku BS, Fields JM, Santana A, Wasserman D, Borman L, Scott KC. The urban homeless: super-users of the emergency department. Popul Health Manag. 2014 Dec;17(6):366-71. doi: 10.1089/pop.2013.0118. PMID: 24865472.

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