Emergency Department Utilization – Navigating Members to the Appropriate Care Pathways


Excess emergency department utilization for ambulatory-sensitive conditions presents an ongoing challenge for payers, adversely impacting the health status of members, and cost and quality performance.   Integra offers a solution that is easy and quick to implement and – as with all of our community-based solutions – is based on addressing social, environmental and behavioral factors that are likely to trigger avoidable ED visits.

Our clients identify members who have histories of excessive ED utilization.  We engage and work with these members over a 30-day period to make sure they have the knowledge, capability and access needed to make appropriate use of primary, urgent care and specialty health care services in lieu of repeated ED visits.

Integra’s advanced Community Health Worker service model is at the core of the program, equipping members, families and caregivers with a personal guide to understand, access, and successfully navigate appropriate heath care and social services to avoid inappropriate ED utilization.   Starting with our client’s ‘chase list’ of members at risk for avoidable ED utilization, our Community Coordinators locate, contact and engage these members and work with them throughout the 30-day program to improve health behavior and utilization patterns contributing to excess ED use.

Our Community Coordinators provide education, advocacy and support to help the members address day-to-day barriers associated with Social Determinants of Health (SDOH), such as health literacy and transportation, that foster patterns of inappropriate and excess ED utilization.  We help reshape these patterns through appropriate use of primary care, behavioral and other specialty care, urgent care, community resources and other payer benefits like Nurse Line services, and prescription maintenance and adherence.

The Relationship Between of Behavioral Health and ED Utilization

While our Emergency Department Utilization program is applicable to virtually all member populations, it can be particularly effective for members with unmet/under-addressed behavioral health needs and those grappling with Serious Mental Illnesses (SMI) such as schizophrenia and Bipolar Disorder.  Behavioral health is directly or indirectly tied to many avoidable ED visits, yet behavioral disorders go undiagnosed and even undetected in many people.  Additionally, non-adherence to medication is a frequent reason for excess ED utilization. For this reason, payers are increasingly implementing initiatives designed to detect and address unmet behavioral health needs among their members.

When working with a member, our Community Coordinators:

  • Visit the member in the home or, if necessary, shelter
  • Ensure member has adequate supply of prescribed medications and understands the medication schedule
  • Establish primary care, behavioral and other specialty care and other provider relationships on a timely basis
  • Educate member on appropriate use of Urgent Care and available Nurse Line services for non-emergency, after-hour services
  • Provide appointment reminders and arrange transportation if necessary
  • Identify and address other SDOH barriers to appropriate healthcare utilization

During the 30-day duration of the program, the member’s Community Coordinator is available 24/7 to answer any questions and provide additional support and coordination as needed. At the end of this period the Community Coordinator transitions the member to the client’s care or case management team as appropriate.

Contact us about implementing our Emergency Department Utilization program for your members.