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June 28, 2016

Part doctor's office, part ED: How Kaiser's 'hubs' reduce ED visits

Daily Briefing

Editor's note: This popular story from the Daily Briefing's archives was republished on May 21, 2019.

Kaiser Permanente, Mid-Atlantic States (KPMAS) has lowered costs and increased access to care through multispecialty hubs that move some aspects of emergency care out of the ED, Mid-Atlantic Permanente Medical Group executives Robert Pearl and Bernadette Loftus write in NEJM Catalyst.

Primer series: How to address avoidable ED utilization

Patients with urgent medical problems often lack better options than the ED, Pearl and Loftus write. Doctors' offices, they argue, aren't equipped to handle particularly complex cases; urgent care centers and freestanding EDs don't provide advanced lab and imaging facilities or a broad array of specialists; and retail clinics tend to help only patients with minor health issues. 

To address those gaps in service, KPMAS in 2012 launched five multi-specialty hubs after internal research found that 91 percent of KPMAS patients treated at EDs could obtain appropriate care through a hub with medical, surgical, and diagnostic services.

The hubs are located adjacent to multi-specialty medical offices and are open 24/7. During the day, the hubs include doctors from nearly all specialties, while a "full range of specialists are on call nights and weekends," Pearl and Loftus write.

The hubs serve all patients who do not need multi-day inpatient admission or transport via an ambulance. Those with complex and pressing medical problems can be treated quickly by emergency medicine physicians and other specialists, but patients can also seek treatment for more minor conditions, such as ear infections or muscle sprains.

The hubs also have advanced testing and diagnostic capabilities on-site, and they even have on-site ORs for minor and moderately complex surgeries.

The specialty hubs use the same EHR system as other KPMAS facilities, so the care team has access to each patient's full medical history. Patients can stay up to 23 hours before being discharged, and those who need to be hospitalized can bypass the ED for quick admission directly to a Kaiser partner hospital.

The hubs contributed to a 23 percent drop in ED visits and hospital days per 1,000 KPMAS members between 2009 and 2014.

Pearl and Loftus write that of the 700,000 patients treated in the hubs in the past six years, 31 percent would otherwise have used an ED to receive care—and only 2 percent of those patients went on to be admitted to a hospital. "Across that time," they add, "there have been no major medical complications or avoidable patient deaths."

The hubs also rank high in patient satisfaction: In 2015, 86 percent of hub patients reported a very good or excellent care experience.

Challenges of the hub model

The hubs cost only about 20 percent as much to construct as a hospital does, but Pearl and Loftus note that there is a "major" capital investment in sophisticated monitoring equipment and machines. The hubs also face hiring challenges, similar to those other health care institutions are facing.

"Yet as the United States struggles to address the health care challenges it faces, new models for care delivery will be essential," they write (Bird, FierceHealthcare, 6/23; Pearl/Loftus, NEJM Catalyst, 6/22). 

Primer series: How to address avoidable ED utilization

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