Primary Care Practice Structural Capabilities and Emergency Department Utilization Among High-Need High-Cost Patients

Abstract

Background: US primary care practices are actively identifying strategies to improve outcomes and reduce costs among high-need high-cost (HNHC) patients. HNHC patients are adults with high health care utilization who suffer from multiple chronic medical and behavioral health conditions such as depression or substance abuse. HNHC patients with behavioral health conditions face heightened challenges accessing timely primary care and managing their conditions, which is reflected by their high rates of emergency department (ED) utilization and preventable spending. Structural capabilities (i.e., care coordination, chronic disease registries, shared communication systems, and after-hours care) are key attributes of primary care practices which can enhance access and quality of chronic care delivery.

Objective: The purpose of this study was to analyze the association between structural capabilities and ED utilization among HNHC patients with behavioral health conditions.

Design and measures: We merged cross-sectional survey data on structural capabilities from 240 primary care practices in Arizona and Washington linked with Medicare claims data on 70,182 HNHC patients from 2019.

Key results: Using multivariable Poisson models, we found shared communication systems were associated with lower rates of all-cause and preventable ED utilization among HNHC patients with alcohol use (all-cause: aRR 0.72, 95% CI: 0.62, 0.84; preventable: aRR 0.5, 95% CI: 0.40, 0.64) and HNHC patients with substance use disorders (all-cause: aRR 0.76, 95% CI: 0.68, 0.85; preventable: aRR 0.61, 95% CI: 0.52, 0.71). Care coordination was also associated with decreased rates of ED utilization among the overall HNHC population and those with alcohol use, but not among HNHC patients with depression or substance use disorders.

Conclusion: Shared communication systems and care coordination have the potential to increase the effectiveness of primary care delivery for specific HNHC patients.

Keywords: emergency utilization; high-need high-cost; nurse practitioner workforce; primary care; structural capabilities.