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ED Capacity and Overcrowding
For 2014, California hospitals reported 306085 patients
had left their ED’s during the year without being seen. They
also reported 72572 total hours of diversion time, when
their ED’s were operating beyond capacity and unable to
accept new patients arriving by ambulance. Peak hours on
diversion were in January 2014, when ED’s statewide were
closed to ambulance patients 4.09% of the time. During a
twelve-month period ending in March 2014, they reported
the average time for patients admitted to inpatient status
to reach their hospital beds from arrival in the ED was 340
minutes (19).
Frequent Visitors to Emergency Departments
One of the systemic challenges facing crowded ED’s is that
large percentages of visits are attributable to a very small
number of patients. A recent Harvard study suggested that
more than one set of independent demographic and func-
tional metrics can be used to predict which ED patients are
at greatest risk for admission or readmission (20).
A study published in 2015 from UCSF based on ambulance
transport data in San Francisco showed two important
sub-populations that are consistent with the finding of
other studies of frequent ED visitors. Moderate use (2-4
ambulance arrivals per year) is strongly associated with
older age, fragility, and MCC. Many also have deficits in
cognition, mobility, and community care presenting chal-
lenges to primary care. Super-users (15 or more ambulance
arrivals per year) tended to be middle-aged, male, with
a strong association with acute-on-chronic alcohol use.
Super-users accounted for only 0.3% of all ED patients but
consumed more than 6% of all EMS/ED resources during the
study period (21).
Psychiatric Emergency Care
At the beginning of 2015, there were only 29 hospitals
licensed by the state of California for acute psychiatric
care with only 2557 beds. During 2014 they rendered only
683669 days of inpatient care during 90493 admissions for
psychiatric care. Such facilities are often legally structured
to isolate them from requirements on general acute care
hospitals to screen and stabilize all patients for emergency
medical conditions. The total number of acute inpatient
psychiatric beds has been dropping for several decades in
the US because of changes in treatment and health insur-
ance payment standards.
Because of unmet needs in communities, multiple studies
have shown that 10-12% of all ED visits are now because
of mental health emergencies, often compounded by
substance abuse issues. Waiting or boarding times for ED
patients with psychiatric emergencies has been reported
at 10-12 hours in California, and is often measured in
days for patients without private health insurance. Some
communities are beginning to develop specialized outpa-
tient treatment centers for behavioral health. Under the
Psychiatric Emergency Service model (PES) developed in
Alameda County, after intensive assessment and treatment,
most patients with urgent mental health problems can be
safely discharged home. Waiting times in Basic ED’s able to
transfer patients with psychiatric emergencies to PES facili-
ties have dramatically dropped (23).
INTEGRATING EMERGENCY CARE
In 2015, most health care in California was provided
through three separate industries. With some exceptions
in rural areas and government-owned facilities, California’s
hospitals were privately operated in competition with each
other. Government-sponsored health insurance programs
like Medicare and MediCal operated separately from
several dozen private health insurance programs. And the
vast majority of physicians continued to practice in small,
single-specialty groups in one region. The fragmented
nature of all three industries contributed to many of the
inefficiencies of emergency care in California described
above.
In contrast, approximately 18% of California residents are
covered by closely related entities known collectively as
Kaiser Permanente. KP includes a non-profit health insur-
ance program, a non-profit system of hospitals, and the
Permanente medical groups, which operate many of their
own clinics. As a population, KP members were shown to be
comparable to Californians covered by other private health
insurance programs in terms of age, race, and employ-
ment status; KP members had lower mean income level
(24). Kaiser contracts with Medicare to care for nearly one
million members of their MA program in California. Making
up nearly 13% of all KP members, this population of elderly
or permanently disabled Californians had risk adjustment
scores comparable to the rest of Medicare members in
California (0.935 and 0.947, respectively for Northern
California, and 0.969 and 0.977 for Southern California).
KP is also the largest integrated care system in the US,
referred to as an ‘accountable care organization’ (ACO) in
the ACA. KP aspires to achieve the Triple Aim: improving the
care of individual patients, promoting overall population
health, and reducing per capita health insurance costs.
Because KP is unique in California in terms of scale as well
as integration, it may provide a model for optimizing the
acute care continuum. Several outcome trends were seen
[REV. MED. CLIN. CONDES - 2017; 28(2) 178-185]