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Study says coordinated care could help address disabled adults' high ED use

While only 17 percent of the working age U.S. population, adults with disabilities account for disproportionately high (almost 40 percent) emergency department visits, according to a recent study from National Institutes of Health (NIH) researchers.

According to the research, which included analyzed data from the Medical Expenditure Panel Survey, adults with disabilities also accounted for 65 percent of patients who visit the ED more than four times a year, and those with a severely limiting disability visited an urgent care department more often than their peers. Emergency visits were also associated with poor access to primary medical care, which was more prevalent among adults with disabilities.

"We want to understand what takes people to the emergency department to learn if their care could be better managed in other ways," said Elizabeth Rasch, chief of the Epidemiology and Biostatistics Section in the NIH Clinical Center's Rehabilitation Medicine Department, in a press release. "While many of those visits may be necessary, it is likely that some could be avoided through better information sharing among all of the healthcare providers who see a particular individual."

"We approached this study in much the same way as we would if we were investigating health service utilization by women or by particular racial or ethnic population groups," said Stephen Gulley, research associate with the Rehabilitation Medicine Department of the Clinical Center at NIH. "We already knew that people with disabilities rely upon a wide array of health- and community-based services, but little was specifically known about their use of emergency departments and our goal with the study was to begin to change that."

Gulley and his fellow researchers found that the driving forces behind the high ED visit rates are very complex.

"It is true that some of the highest rates of use are by people with disabilities who are experiencing problems with access to healthcare or lack of insurance coverage. However, we also found that the lion's share of people with disabilities are individuals who are managing multiple encounters across the healthcare system, whether with primary care doctors, medical specialists, therapists, pharmacies or hospitals," he said.  Many of those 'high flyers' in the healthcare system also end up in the ED more than once in the average year, particularly if managing multiple chronic health or mental health conditions and especially if their disabilities are associated with a need for ongoing help with activities of daily living, such as bathing, dressing or taking medications."

Gulley and the report's other authors made recommendations for provider and policymaker actions to offset some of the need for emergency care by individuals with disabilities. According to the report, prevention and chronic condition management programs tailored for the functional limitations and service needs of people with disabilities may help avoid a crisis situation that would call for an urgent care visit. The authors also endorsed wider adoption of coordinated care systems for the disabled that provide case management, integration of psychosocial care and 24/7 access to medical assistance, among other services.

"On behalf of people with disabilities, we may need to view an ED visit as an opportunity, or perhaps even a series of them. First, when a person comes to the ED uninsured or reporting that they do not have a primary care doctor, we need to follow up on that, in partnership with the patient or their family," said Gulley. "Second, we need to establish a reliable, multi-way path of health information technology that links ED providers with others involved in the individual's care.  In this way, the ED staff should have access to the patient's full medical history, as well as recent lab tests and notes from treating physicians."

When a patient is admitted to the emergency department, sharing detailed medical information between emergency room and primary care staff could prevent repeat visits, noted the report. Gulley added that care coordination is particularly important for disabled patients as they may have limitations that interfere with medical self-advocacy and complex conditions that demand care from various providers.