The Everyday Pledge: Meeting patient needs outside of emergency care

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By Amy Yuen

Since its inception as a breakfast meeting for primary care providers 16 years ago, the Camden Coalition of Healthcare Providers has zeroed in on addressing the causes and consequences of excessive hospital utilization. The Everyday Pledge is a pilot program to connect Camden residents who are visiting the emergency department about once a month to primary care providers who can offer them education and support. Often, the factors driving patients to emergency departments are gaps in social services, and in many cases, patients lack access to or strong relationships with their primary providers.

To reduce overuse of Camden’s emergency departments and improve patient access to more appropriate care, the Camden Coalition is partnering with several hospitals and primary care providers across the city to connect patients to services that can better address their needs. The Everyday Pledge focuses on individuals who use emergency departments at moderately high rates — five to seven times over a six-month period — rather than people who use them at extremely high rates. The program sets up incentives that encourage patients to follow up with their primary care providers within 14 days of discharge, and gives the providers tools to address social drivers of health.

“Unnecessary emergency visits represent a significant amount of healthcare spending, and reduce the ability of emergency department staff from focusing on true medical emergencies,” said Carter Wilson, Associate Director for Clinical Redesign Initiatives at the Camden Coalition. “Through the Everyday Pledge, we want to build understanding of the patient-specific needs that drive the overuse of emergency departments, and ensure that the underlying needs of these patients are being met and accounted for in treatment plans.”

The Everyday Pledge builds upon the insights from our SeekED pilot, which focused on patients who visited the emergency department more than 50 times in six months. Through SeekED, we learned that patients with extremely high emergency department utilization rates are often already connected to primary care, but that those with medical complexity do not consistently engage with primary and specialty care. These patients were also found to have high rates of behavioral health diagnoses, substance use, or housing instability, in contrast to those with moderately high utilization.

 
The Everyday Pledge model

The Everyday Pledge model mirrors some aspects of the 7-Day Pledge approach, but instead of focusing on frequently hospitalized patients, the new pilot targets patients with high rates of emergency department use who have conditions that are likely mitigable by primary care. Using real-time data from hospital emergency departments, the Coalition identifies patients who have had moderately high utilization over a period of six months. Our staff immediately alerts their primary care providers to engage with them about the drivers behind their emergency department visits over the phone, and schedule follow-up appointments. Patients with an acute medical need are given urgent priority appointments.

Busy practices are awarded by the Coalition with financial incentives to support their work with the Everyday Pledge: $100 for appointments attended by patients within 14 days of their emergency department visits, and for completing emergency department driver forms. At the appointments, providers use My Resource Pal to screen patients for a range of social needs, and help connect them to community resources that can address their concerns. Coalition staff are also convening monthly meetings with the practices to review the root causes of patient emergency department use and share findings.

“Our goal is to support Camden providers with the resources they need to give their patients effective, person-centered care,” said Carter.

The Camden Coalition is closely collaborating with several hospitals to implement the Everyday Pledge: Cooper University Health Care, Lourdes Health System, Virtua Health, and Jefferson Health’s three New Jersey hospitals. Our partnering primary care providers include: CAMcare, Cooper Family Medicine, Cooper Internal Medicine, Cooper Pediatrics, Fairview Village Family, Kyle W. Will Family Health Center, Osborn Family Health Center, Project H.O.P.E., and Reliance Medical Group.

To learn more about the program, visit our Everyday Pledge webpage.

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