Population Health Management at Norwalk Hospital: Characteristics of Frequent Visitors to the Emergency Departmen

Background: As hospitals enter risk-sharing agreements to manage groups of high-risk patients, population health management efforts are being implemented with a goal of reducing costs for the highest-utilizing groups of patients accounting for a disproportionate share of emergency department (ED) visits and inpatient stays. Hospitals are putting plans in place to assess and intervene in social determinants of health for some of their most vulnerable patients.;Purpose: To determine patient characteristics and their association with frequent use of the ED at one large hospital in CT.;Methods: A retrospective chart review was used to collect information regarding: demographics; housing status; mental health and substance misuse diagnoses; chronic disease; outpatient primary care and mental health providers; insurance type and frequency of hospital usage. Descriptive statistics and bivariate analysis were used to identify statistically significant characteristics in relation to the frequency of hospital usage.;Results: High-risk frequent visitors at the hospital presented with increased rates of chronic disease, substance misuse and mental health diagnosis. Certain groups and sub-groups of patients accounted for disproportionate shares of ED visits and inpatient stays. Statistically significant correlations were identified between many characteristics. Notably, a positive correlation at the .01 level exists between: being a male, being homeless; having an alcohol misuse diagnosis and being Hispanic; being identified as dual diagnosis and polysubstance misuse disorder and having a primary care physician while having no substance misuse diagnosis. Statistically relevant correlations were identified between having a substance misuse diagnosis and being a male; between having inpatient stays and having an alcohol misuse diagnosis; between having made inpatient stays and being on the schizophrenia spectrum and between being Hispanic and having a substance misuse diagnosis.;Discussion/Conclusion: The role of social work leadership in this process is imperative as successful population health management relies on effective care coordination both inside and out of the hospital. The results provide relevant information for medical providers when addressing the health of the hospital's most vulnerable population. From a population health management perspective, attention should be paid to connecting frequent visitors to services around: housing; treatment for alcohol misuse disorder with increased efforts to connect Hispanic individuals with alcohol misuse diagnosis to culturally relevant support and treating frequent visitors with dual diagnosis with non-addictive psychiatric medications.