Navigating Complexity: Transforming Emergency Care for Vulnerable Patients

Elizabeth Kayser and Ayesha Khan, MD, MPH are developing complex care plans for frequent ED visitors.

A pilot program targeting frequent ED visitors has reduced ED recidivism and inpatient admissions and saved $710,000 in the first six months while enhancing care pathways.

 

Emergency departments (EDs) are often the first line of care for acute medical needs. However, many patients—colloquially dubbed "frequent fliers"—do not present with actual emergencies. Instead, they return repeatedly due to difficulties in navigating their complex social and medical needs. For a number of patients, the ED becomes a source of primary, non-urgent healthcare, further straining ED resources.

Launched in January 2023, the Stanford ED Complex Care Program specifically targets individuals who have made more than six visits to the emergency department (ED) in the last six months and focuses on patients facing multiple social and medical challenges. 

Often these patients have multiple intricately linked social needs, such as no or inadequate insurance, language barriers, literacy issues, mental health, and addiction. 


Bridging the Gap with Synoptic Analysis

Usually, when a patient has social needs, they have to express them to a provider at the bedside to garner resources or assistance. However, not all patients can do so.

Additionally, as Ayesha Khan, MD, MPH, program co-creator, notes, “The challenges keeping people from navigating the system go beyond things like logistical barriers, or psychosis or addiction; they encompass a multifactorial nature of social needs that the patient may not be able to express or summarize.”

The Complex Care Program transcends traditional bedside assessments, which often miss critical contextual factors. Instead, this approach adopts a synoptic analysis method that creates detailed timelines of the patient's medical histories and social determinants - in advance - looking for patterns and enabling a holistic understanding of their challenges. 

Step 1: Program co-creator and Stanford high-risk social worker Elizabeth Kayser uses a synoptic lens to conduct a detailed patient chart analysis of frequent ED visitors. Her study includes behavioral patterns, social determinants of health and systemic barriers. She also identifies actionable gaps.

Step 2: Khan reviews the medical needs and invites relevant specialists— pain management, addiction services, and various medical disciplines like cardiology or hematology—to collaborate on a Complex Care Plan flagged in the patient’s chart and tailored to the patient's unique circumstances. 

If any aspect of the care plan deviates from standard emergency medicine care the medical ethics team is consulted. Khan and Kayser also coordinate with outpatient teams, case managers, and other stakeholders to implement interventions. 


The Iteration of Innovation 

The Complex Care Plan in its current form has roots in a 15-year effort at Stanford Medicine to address the unique needs of frequent visitors. Karen Stuart, RN, manager of emergency services for Stanford emergency department, has long been an advocate for the work and previously collaborated with Stanford Emergency Medicine physicians Laleh Gharahbaghian and Shashank Ravi to create a foundation of support within the hospital.

Kayser explains, “This methodology has shown measurable success in addressing not only the clinical needs of patients but also their social, emotional, and systemic challenges. With each case, the approach continues to evolve, creating more opportunities to refine and enhance care delivery. It’s been an incredible experience to witness the positive impact of these efforts on patients’ lives, offering sustainable solutions while honoring their dignity and resilience.” 


Success Stories and Cost Savings

A recent success involves a patient with a chronic skin condition that led to frequent ED visits for pain management. Although on medical assistance, the patient struggled to access effective treatment. And while he managed to secure a referral to a pain clinic, he was stymied by a requirement that he first see multiple specialists for consultation prior to being given a clinic appointment. 

Using the Complex Care Plan, during the patient’s next ED visit, the physician directly contacted a plastic surgeon to consult in the ED and cleared the way  for the patient to get an appointment with the pain clinic. As a result, the patient received a comprehensive outpatient pain management plan, significantly reducing his reliance on emergency services.

The program has already shown measurable improvements, including reduced ED recidivism and inpatient admissions. An early analysis indicated the hospital saved $710, 000 in direct costs over six months due to enhanced care pathways.

Khan emphasizes, “Our success is evident when we connect patients with the best medical care or provide them with the social resources they need to lead healthier lives.”


Looking Ahead

Looking ahead, the program plans to incorporate data analysis and artificial intelligence to create a more efficient response for patients facing systemic barriers. However, Khan stresses the importance of doing this ethically, prioritizing patient care above all, noting, “True innovation isn’t always high-tech. It’s about finding creative solutions to address urgent social and medical challenges.” 

 

2024