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Implementing a case management intervention for frequent users of the emergency department (I-CaM): an effectiveness-implementation hybrid trial study protocol.

ABSTRACT: BACKGROUND:ED overcrowding represents a significant public health problem in developed countries. Frequent users of the emergency departments (FUEDs; reporting 5 or more ED visits in the past year) are often affected by medical, psychological, social, and substance use problems and account for a disproportionately high number of ED visits. Past research indicates that case management (CM) interventions are a promising way to reduce ED overcrowding and improve FUEDs' quality of life. There is, however, very limited knowledge about how to disseminate and implement this intervention on a large scale to diverse clinical settings, including community hospitals and non-academic centers. This paper describes the protocol of a research project aiming to implement a CM intervention tailored to FUEDs in the public hospitals with ED in the French-speaking region of Switzerland and evaluate both the implementation process and effectiveness of the CM intervention. METHODS:This research project uses a hybrid study design assessing both implementation and clinical outcomes. The implementation part of the study uses mixed methods a) to describe quantitatively and qualitatively factors that influence the implementation process, and b) to examine implementation effectiveness. The clinical part of the study uses a within-subject design (pre-post intervention) to evaluate participants' trajectories on clinical variables (e.g., quality of life, ED use) after receiving the CM intervention. We designed the study based on two implementation science frameworks. The Generic Implementation Framework guided the overall research protocol design, whereas the RE-AIM (reach, efficacy, adoption, implementation and maintenance) framework guided the implementation and effectiveness evaluations. DISCUSSION:This research project will contribute to implementation science by providing key insights into the processes of implementing CM into broader practice. This research project is also likely to have both clinical and public health implications. TRIAL REGISTRATION:NCT03641274 , Registered 20 August 2018.

SUBMITTER: Grazioli VS

PROVIDER: S-EPMC6330435 | biostudies-literature | 2019 Jan

REPOSITORIES: biostudies-literature

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Implementing a case management intervention for frequent users of the emergency department (I-CaM): an effectiveness-implementation hybrid trial study protocol.

Grazioli Véronique S VS Moullin Joanna C JC Kasztura Miriam M Canepa-Allen Marina M Hugli Olivier O Griffin Judy J Vu Francis F Hudon Catherine C Jackson Yves Y Wolff Hans H Burnand Bernard B Daeppen Jean-Bernard JB Bodenmann Patrick P

BMC health services research 20190111 1

<h4>Background</h4>ED overcrowding represents a significant public health problem in developed countries. Frequent users of the emergency departments (FUEDs; reporting 5 or more ED visits in the past year) are often affected by medical, psychological, social, and substance use problems and account for a disproportionately high number of ED visits. Past research indicates that case management (CM) interventions are a promising way to reduce ED overcrowding and improve FUEDs' quality of life. Ther ...[more]

PMID: 30634955

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Project description:Background:Older adults in the emergency department (ED) are at high risk for functional decline, unrecognized delirium, falls, and medication interactions. Holistic assessment by a multidisciplinary team in the ED decreases these adverse outcomes and decreases admissions, but there are many barriers to incorporating this type of care during the ED visit. Methods:This is a hybrid type II effectiveness-implementation study using a pre-/post-cohort design (n?=?380) at a tertiary care academic ED with an ED observation unit (Obs Unit). The intervention is a two-step protocol of (step 1) ED nurses screening adult patients ??65?years old for geriatric needs using the Delirium Triage Screen, 4-Stage Balance Test, and the Identifying Seniors at Risk score. Patients who have geriatric needs identified by this screening but who do not meet hospital admission criteria will (step 2) be placed in the Obs Unit for multidisciplinary geriatric assessment by the hospital's geriatric consultation team, physical therapists, occupational therapists, pharmacists, and/or case managers. Not all patients may require all elements of the multidisciplinary geriatric assessment. The Consolidated Framework for Implementation Research: Care Transitions Framework was used to identify barriers to implementation. Lean Six Sigma processes will be used to overcome these identified barriers with the goal of achieving geriatric screening rates of >?80%. Implementation success and associated factors will be reported. For the effectiveness aim, pre-/post-cohorts of adults ??65?years old cared for in the Obs Unit will be followed for 90?days post-ED visit (n = 150 pre and 230 post). The primary outcome is the prevention of functional decline. Secondary outcomes include health-related quality of life, new geriatric syndromes identified, new services provided, and Obs Unit metrics such as length of stay and admission rates. Discussion:A protocol for implementing integrated multidisciplinary geriatric assessment into the ED setting has the potential to improve patient functional status by identifying and addressing geriatric issues and needs prior to discharge from the ED. Using validated frameworks and implementation strategies will increase our understanding of how to improve the quality of ED care for older adults in the acute care setting. Trial registration:ClinicalTrials.gov Identifier, NCT04068311, registered 28 August 2019.

Project description:BACKGROUND:Frequent emergency department users are patients cumulating at least four visits per year. Few studies have focused on persistent frequent users, who maintain their frequent user status for multiple consecutive years. This study targets an adult population with chronic conditions, and its aims are: 1) to estimate the prevalence of persistent frequent ED use; 2) to identify factors associated with persistent frequent ED use (frequent use for three consecutive years) and compare their importance with those associated with occasional frequent ED use (frequent use during the year following the index date); and 3) to compare characteristics of "persistent frequent users" to "occasional frequent users" and to "users other than persistent frequent users". METHODS:This is a retrospective cohort study using Quebec administrative databases. All adult patients who visited the emergency department in 2012, diagnosed with chronic conditions, and living in non-remote areas were included. Patients who died in the three years following their index date were excluded. The main outcome was persistent frequent use (≥4 visits per year during three consecutive years). Potential predictors included sociodemographic characteristics, physical and mental comorbidities, and prior healthcare utilization. Odds ratios were computed using multivariable logistic regression. RESULTS:Out of 297,182 patients who visited ED at least once in 2012, 3,357 (1.10%) were persistent frequent users. Their main characteristics included poor socioeconomic status, mental and physical comorbidity, and substance abuse. Those characteristics were also present for occasional frequent users, although with higher percentages for the persistent user group. The number of previous visits to the emergency department was the most important factor in the regression model. The occasional frequent users' attrition rate was higher between the first and second year of follow-up than between the second and third year. CONCLUSIONS:Persistent frequent users are a subpopulation of frequent users with whom they share characteristics, such as physical and mental comorbidities, though the former are poorer and younger. More research is needed in order to better understand what factors can contribute to persistent frequent use.

Project description:ObjectivesMany interventions have been developed over the years to offer frequent users of the emergency department (FUEDs) better access to quality coordinated healthcare. Despite recognising the role primary care physicians (PCPs) play in FUEDs' care, to date their perceptions of case management, the most studied intervention, have rarely been assessed. Furthermore, a gap regarding PCPs' experience of caring for FUEDs persists. Thus, this study aimed to explore PCPs' perceptions of the care provided to FUEDs in emergency and primary care settings, their views on the local case management team (CMT), and their suggestions to improve FUEDs' care.DesignQualitative study using in-depth semistructured interviews and inductive thematic analysis.SettingCanton of Vaud, Switzerland.ParticipantsThirty PCPs participated, 16 in private practice (PP-PCPs) and 14 based at the Lausanne University Centre of General Medicine and Public Health (Unisanté-U-PCPs).ResultsU-PCPs and PP-PCPs thought that most FUEDs' emergency department (ED) visits were legitimate, but questioned ED adequacy to meet FUEDs' needs. Yet, both PCP groups reported encountering many challenges in FUEDs' care themselves. In this context, PP-PCPs seemed more satisfied of the care they provided to FUEDs than U-PCPs. Generally, U-PCPs seemed to find more value in the CMT to help them care for FUEDs than PP-PCPs. To enhance FUEDs' care, U-PCPs and PP-PCPs suggested enhancing collaboration with other healthcare providers. U-PCPs also wished to increase their availability, and some PP-PCPs considered outpatient clinics, larger group practices or medical centres most appropriate to handle FUEDs' needs.ConclusionsThis study highlights the many challenges PCPs face in caring for FUEDs, that a CM intervention has the potential to mitigate, and provides ways forward in improving FUEDs' care, including reinforced communication with the CMT and ED physicians, and structural changes to their own way of delivering care to FUEDs.

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Implementing a case management intervention for frequent users of the emergency department (I-CaM): an effectiveness-implementation hybrid trial study protocol.

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Implementing a case management intervention for frequent users of the emergency department (I-CaM): an effectiveness-implementation hybrid trial study protocol.

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