The rise of the specialty emergency department

(This article has been updated with a correction.)

More than 10% of Mount Sinai Hospital's 110,000 emergency department visits each year involve patients over age 65. Three years ago, the 1,048-bed New York City hospital—which is participating in a Medicare shared-savings accountable care organization—opened a dedicated geriatric ED designed to help coordinate care for these higher-risk patients.

“There's sort of a silver tsunami approaching,” said Dr. Denise Nassisi, director of geriatric emergency medicine at Mount Sinai. “We planned it because we knew that geriatric patients really do require special handling.”

Across the country in Newport Beach, Calif., Hoag Memorial Hospital Presbyterian last August introduced an obstetrics emergency department to serve the mini baby boom now underway, which is being fed in part by an uptick in the insured population. Many expectant mothers with complaints unrelated to pregnancy were still visiting the ED because they didn't yet have a primary-care physician.

“What we found was that many of the patients who came into the general emergency department came in for conditions unrelated to pregnancy,” said Dr. Allyson Brooks, executive medical director of the Hoag Women's Health Institute. But the staff in the general ED often felt uncomfortable treating pregnant patients. “The patient was caught in the middle.”

Patients now see an OB-GYN within 45 minutes, increasing their satisfaction and reducing unnecessary admissions. “It's more coordinated care,” Brooks said.

The major investments in specialty EDs at Mount Sinai and Hoag Memorial are part of a broader trend across the country. ED visits, which are the starting point for about half of all hospital admissions, are continuing to grow, despite the dramatic decline in the uninsured rate brought about by the Affordable Care Act's insurance and Medicaid expansions.

In part that's because the number of newly insured patients is growing faster than the number of primary-care physicians available to treat them. “With the stroke of a pen, we can increase the number of patients covered, but it takes time to increase the infrastructure for primary care,” said Raphe Schwartz, a director at the Chartis Group, a management consulting firm.

Emergency departments have become a significant source of revenue for hospitals. At the same time, some of that revenue is under pressure as the CMS has set new guidelines for determining whether short hospital stays should be billed as inpatient or outpatient care. A report last year from Moody's Investors Service calculated that that the “two-midnight rule” has the potential to reduce average reimbursement by up to $4,000 per case.

Patients, meanwhile, have come to view the ED as a sort of high-tech, 24/7 urgent-care center. Even patients who have a relationship with a doctor are often sent directly to the emergency department by their primary-care physician, a 2013 study from RAND Health found. Nearly three-fourths of emergency medicine doctors also reported that they're under significant pressure to increase patient satisfaction, according to a survey from the American College of Emergency Physicians.

A small but growing number of hospitals are tackling their ED volume by service line, offering specialty emergency departments for senior citizens, psychiatric patients, pregnant women or children.

A general ED can be an overwhelming, chaotic place, throwing together people arriving with contagious illnesses or trauma with those who come in the midst of a psychiatric crisis or drug withdrawal. It's not the best environment for children, women in labor or the elderly.

“The care in the geriatric ED has a lot more amenities because seniors need that,” said Dr. Mark Rosenberg, chairman of the emergency medicine department at St. Joseph's Healthcare System, based in Paterson, N.J. “It's quiet, it's comfortable, it's organized.”

The specialty ED can relieve pressure from the general emergency department by treating patients with less acute needs. It can also help hospitals tap into a lucrative patient demographic or offer better workflow for office-based physicians.

When Mount Sinai designed its geriatric ED, it strove to create a more appealing physical space, with nonskid floors, noise-reducing curtains and readily available reading and hearing aids. But clinicians have also focused on improving care transitions, Nassisi said.

The geriatric ED has reduced unnecessary admissions for elderly patients who often come in with delirium or dementia and have multiple chronic conditions, some of which may present differently than they do in younger patients. “The approach in the past … was too complex to sort it all out in the emergency department,” Nassisi said. That meant patients were often admitted when they didn't need to be—despite research showing that elderly patients have a hard time returning to activities of daily living after a hospital stay.

St. Joseph's Regional Medical Center in Paterson opened its geriatric emergency department in 2009. The volume of patients coming through its general ED has swelled to 160,000 a year, up from 76,000 in 2004, after a number of nearby hospitals shut their doors.

“We know that geriatric patients use the emergency department seven times more than their younger cohorts,” Rosenberg said. “We also know that this age group requires significantly more healthcare resources.”

St. Joseph's geriatric emergency department has set the tone for coordinating care for all ED patients. Although the specialty ED has some extra amenities such as thicker mattresses and harpists to provide soothing music, it also connects patients with a team of liaisons who screen for common problems like mental-health or dietary issues. Patients also receive follow-up calls on the first, third and seventh day after they leave the hospital. “Once we improved care for seniors, we improved care for everyone,” Rosenberg said.

Seniors aren't the only patient demographic that's growing. As the economy has improved and more households gain insurance, the birth rate is picking up again, said Renee Nelson, vice president of operations at TeamHealth. The physician staffing company is currently working with its hospital clients to set up six dedicated obstetric EDs.

Women who have a positive birth experience usually stay within the same hospital network for all of their family's healthcare needs, Nelson said. “It's one of the few services that can actually make a profit for a hospital.”

Psychiatric care also has become a more lucrative service line for hospitals as the ACA and earlier mental-health parity legislation has expanded insurance coverage for patients. As hospitals have struggled to manage the influx of psychiatric patients—without enough beds to accommodate them—some have invested in psychiatric EDs or triage centers as a better way to manage mental-health patients in crisis.

The spate of new specialty emergency departments follows earlier efforts to introduce EDs specifically for pediatric patients. Parents like having a dedicated emergency department for their children and are likely to continue using the same hospital network for their family's care.

The number of specialty EDs is likely to grow, said Dr. Jay Kaplan, president-elect of the ACEP, who also practices at Marin General Hospital in Greenbrae, Calif. Hospitals are looking at various ways to capture additional emergency department volume, in the same way they've been building free-standing EDs to expand their geographic coverage.

The increased patient volume coming through the emergency department is a revenue opportunity for hospitals that derive most of their payments from fee-for-service contracts. But it's a fiscal roadblock for providers looking to reduce the cost of care under a payment-for-value model, like an ACO.

“For those hospitals taking risks, you'll continue to see investments in lower-cost settings,” said the Chartis Group's Schwartz. Instead of a geriatric ED, for instance, those providers might think about geriatric medical homes, he said.

Schwartz pointed to one hospital client that chose to open 15 ambulatory-care sites in underserved areas. The hospital, which is participating in a Medicare ACO, followed 50,000 patients over about two years and saw an 11% reduction in ED visits.

Yet there's likely only so much that hospitals can do to divert patients from the ED. Kaplan cited a recent study that found 96% of patients visiting emergency departments had a condition that needed to be seen within two hours.

“It is a myth that people are seeking care that don't need to be there,” he said.

So as ED volume continues to increase, hospitals also are making improvements inside the emergency department itself.

St. Joseph Medical Center in Bellingham, Wash., started seeing a surge in its ED volume at the end of last summer. Patient volume increased from about 160 patients per day to more than 180. A severe flu season then caused daily volumes to climb even further, above 200 patients per day.

Much of that volume is coming from geriatric and behavioral-health patients, said Kelly Espinoza, chief nursing officer at the 253-bed hospital, which is part of PeaceHealth.

At St. Joseph, the challenges associated with its increased volume have been daunting enough that the hospital has contracted with TeamHealth to devise a strategy to get the 35% of its ED patients deemed low-acuity seen and released more quickly. It is setting up a section of the department for making quick assessments.

“Those are the ones who shouldn't be in the ER for more than an hour,” Espinoza said. “This is really applying an urgent-care concept.”

Follow Beth Kutscher on Twitter: @MHbkutscher

(This article has been updated to correct Dr. Mark Rosenberg's name.)