Literature Collection

PURPOSE: Emergency departments (EDs) are a vital component of the United States healthcare system and care for over 130 million patient visits annually. Nonurgent ED visits can contribute to crowding, delays in care, and adverse effects. Many high-utilizing ED patients may present with complex medical, behavioral, and social needs that are not necessarily emergent or urgent in nature. The authors created an Integrated Care Model, called the Multi-Visit Patient (MVP) program, for patients with 5 or more visits to the ED in a rolling 12-month period. The MVP program incorporated an interdisciplinary group of ED leadership and case management (CM) to identify, engage, and intervene with ED MVPs, aiming to improve their ED utilization. Patients received comprehensive screenings for depression, falls, alcohol use disorder, caregiver support, social determinants of health, and more. Based on these screenings, the CM team implemented interventions such as connecting patients with outpatient specialists and linking patients to community-based organizations to optimize stability, wellness, and reduce ED utilization. PRIMARY PRACTICE SETTING: The collaboratively developed MVP program was implemented in the ED of a large, suburban, tertiary care academic hospital. FINDINGS/CONCLUSIONS: The MVP program identified 221 MVP patients over a 20-month period and successfully connected with 89% of them. Of these 221 patients, 78% (172 patients) chose to engage in the MVP program, with 160 completing their engagement with an outcome. Among the patients who completed their engagement and for whom the study could match separate utilization data (151 patients), the study observed a 57% reduction in ED visits. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Case managers play a crucial role in the effectiveness of the MVP program by coordinating comprehensive care for high-utilizing ED patients. The MVP program includes transition of care initiatives designed to improve patient outcomes. Through screenings and targeted interventions, case managers identify and address the complex medical, behavioral, and social needs of MVP patients. This collaborative, interdisciplinary approach underscores the importance of timely and coordinated care, benefiting both patients and the health system. The MVP program exemplifies the critical role of case managers in reducing unnecessary ED visits and enhancing overall patient care.

BACKGROUND: COVID-19 significantly negatively impacted access to care among patients with opioid use disorder (OUD). The Veterans Health Administration (VHA) enacted policies to expand telehealth and medication for OUD (MOUD) during the public health emergency, which offset risk of treatment disruption. In this study, we evaluated gender differences in utilization of behavioral therapy in person and via telehealth, MOUD utilization, and achieving 90-day MOUD retention pre-post pandemic onset, given known gender differences in treatment utilization between men and women. Secondarily, we examined MOUD receipt and retention as a function of in-person vs. telehealth behavioral therapy received over time. METHODS: Using VHA's nationwide electronic health record data, we compared outcomes between men and women veterans, pre- to post-pandemic onset (January 2019-February 2020 vs. March 2020-April 2021). Primary outcomes included receipt of behavioral therapy (in person or telehealth), number of appointments attended, any MOUD, and whether patients achieved 90-day MOUD retention post-induction. RESULTS: Veterans with OUD were less likely to receive behavioral therapy post-pandemic onset, which was driven by marked decreases in in-person care; these effects were strongest among women. The odds of receiving MOUD also decreased pre- to post-pandemic onset, particularly among men. Receipt of or achieving 90-day MOUD retention was differentially related to receipt of behavioral therapy via in person vs. telehealth; telehealth was more strongly associated with these utilization indicators post-pandemic onset-an effect that was more pronounced for men. CONCLUSION: The likelihood of receiving behavioral therapy and MOUD were lower during COVID-19 and varied by gender, with men being less likely to receive MOUD over time and women being less likely to receive in-person behavioral therapy. Behavioral therapy received via telehealth was generally associated with improved MOUD utilization compared to in-person behavioral therapy, but this was less true for women than for men regarding utilization of or achieving 90-day MOUD retention. In addition to the need for further telehealth expansion for veterans with OUD, more research should explore how to better engage men in MOUD treatment and improve adherence to MOUD among women engaged in behavioral therapy.