In New York State, almost half (48%) of emergency room visits are for routine, non-emergency care offered by community health providers or are otherwise preventable. These visits disrupt patients’ lives and strain limited hospital resources. Moreover, communication gaps between hospitals and community health providers mean that patients too often slip through the cracks and do not receive the care they need.
Patients like Winston*, who was in therapy three days per week but regularly visited the emergency room because he was lonely and seeking human connection. Or Angela*, who struggled with chronic asthma, sleep apnea, and depression and frequently went to the emergency room for respiratory concerns that a primary care provider could have addressed.
Advanced Health Network/Recovery Health Solutions (AHN|RHS), operating in affiliation – a behavioral health provider network serving New York City and Long Island – collaborated with the Bronx Regional Health Information Organization (Bronx RHIO) and our provider network to develop and implement actionable, data-driven solutions to this problem. We encourage provider networks nationwide to invest in similar collaborations and technical tools to support equitable, high-quality, patient-centered care delivery.
The data tools we created – Emergency Department Alerts, Emergency Department Patient Registry, and Emergency Department Follow-up Reports – are designed to close communication gaps, empower providers and patients, and connect patients with the routine care they need to avoid future emergency room visits. These tools help providers identify patterns, trends, and insights to inform care delivery interventions.
Good data is meaningless without trained staff and systems in place to make use of it. That’s why we partnered with Primary Care Development Corporation (PCDC) to help our providers establish smart, sustainable workflows that actively utilize data to improve patient care. PCDC coaches considered the unique needs of each practice and leveraged data-driven insights to enhance patient-centered care delivery across the AHN|RHS provider network.
Our implementation of these data-driven tools has had clear and impactful results. One provider in our network reported a 62% increase in patient outreach from May to September 2023, and staff reported discussing patients’ emergency room visits in follow-up appointments in 79% more cases than at baseline.
Another provider reported that their patients’ 30-day readmit rate at the emergency room decreased from 66% in January 2021 to 42% in September 2023 following the implementation of the data analytical tools. The share of patients receiving a follow-up call from their behavioral health provider within 24 hours of an emergency room visit increased from 0% in January 2021 to 90% in September 2023.
As for Winston* and Angela*, the data collected from our new suite of tools empowered them and their providers to break the cycle of preventable emergency room visits. Winston and his behavioral health provider discussed the underlying cause of his emergency room visits – his loneliness – and decided that he should receive therapy five days per week to meet his need for human connection.
Angela’s care team worked with her to find a more effective medication dosage to treat her depressive symptoms. They provided her with additional education and reminders about the importance of regularly using her sleep apnea machine, nebulizer, and asthma pump. The care team also helped Angela set up appointments with a primary care provider and pulmonologist, as well as Medicaid transportation to get to those appointments.
The behavioral health providers in our network have seen significant improvements in provider-patient communication, health outcomes, and patient quality of life because of our investment in tools that provide actionable, measurable data. Effectively implemented, these tools empower us to provide care that centers on each patient’s needs. And helping people access the services they need also helps the community by enabling hospitals to reserve their limited resources for true emergencies.
Community health provider networks across the United States can replicate and enhance the success of this initiative by investing in collaborative relationships between hospitals and outpatient behavioral health providers. Policymakers and other decision makers must also invest in resources, including technological solutions like the data tools we’ve developed, dedicated staff and training, redesigned workflows, and enhanced payment to support staff in implementing new processes.
The data analytical tools and processes we’ve developed are improving outcomes and decreasing costs for patients, providers, and the community. The positive impact of this initiative is a testament to the power of collaborative efforts to efficiently utilize community-based resources and improve patients’ lives.
*Pseudonym to protect patient confidentiality
Nadeem Ramjan is a data strategy, governance, and management leader who supports actionable and measurable data solutions. He is Director of Data Strategy & Analytics at Advanced Health Network/Recovery Health Solutions (AHN|RHS), a comprehensive behavioral health provider network. AHN|RHS provides integrated behavioral health services in an autonomous and cohesive program throughout the five boroughs of NYC, Nassau, Suffolk, and upstate New York. Partnering with insurance plans, medical practices, hospitals and health systems, and other strategic partners, AHN|RHS is dedicated to improving immediate access to quality care and empowering individuals to better manage their health and healthcare needs. AHN|RHS supports a person-centered, integrated healthcare model that focuses on early detection, prevention, and treatment with the goal of avoiding unnecessary emergency room visits and hospital admissions.
