Frequent Flyers

I saw a recent article about how hospitals in washington started to address their frequent flyer problem after the state legislature was considering a law to limit medicare patients to 3 visits a year.

They used all of the stuff we are supposed to use but never do...social work and care plans to address these patients. In the article, the hospitals said...it worked.

It turns out that all it requires is being polite but firm and developing a thorough care plan to force these patients out of our waiting rooms.

I have always suspected that this was the case. Many of the frequent flyers are here because they get something in particular.

There is the guy who gets his vicodin refill once a month. (Stop giving it to him and send him to ortho clinic). The homeless people who sleep in the waiting room. (Have them greeted at the door by the ER doc, cleared and sent back out the door, taking away the incentive to do it.) The chronic "I need urine preg"/std check. (Do aggressive medical screening exams and be honest about ridding us of these folks regardless of whether they can pay or not.)

I saw a recent article about how hospitals in washington started to address their frequent flyer problem after the state legislature was considering a law to limit medicare patients to 3 visits a year. They used all of the stuff we are supposed to use but never do...social work and care plans to address these patients. In the article, the hospitals said...it worked. It turns out that all it requires is being polite but firm and developing a thorough care plan to force these patients out of our waiting rooms. I have always suspected that this was the case. Many of the frequent flyers are here because they get something in particular. There is the guy who gets his vicodin refill once a month. (Stop giving it to him and send him to ortho clinic). The homeless people who sleep in the waiting room. (Have them greeted at the door by the ER doc, cleared and sent back out the door, taking away the incentive to do it.) The chronic "I need urine preg"/std check. (Do aggressive medical screening exams and be honest about ridding us of these folks regardless of whether they can pay or not.)

I saw a recent article about how hospitals in washington started to address their frequent flyer problem after the state legislature was considering a law to limit medicare patients to 3 visits a year.

They used all of the stuff we are supposed to use but never do...social work and care plans to address these patients. In the article, the hospitals said...it worked.

It turns out that all it requires is being polite but firm and developing a thorough care plan to force these patients out of our waiting rooms.

I have always suspected that this was the case. Many of the frequent flyers are here because they get something in particular.

There is the guy who gets his vicodin refill once a month. (Stop giving it to him and send him to ortho clinic). The homeless people who sleep in the waiting room. (Have them greeted at the door by the ER doc, cleared and sent back out the door, taking away the incentive to do it.) The chronic "I need urine preg"/std check. (Do aggressive medical screening exams and be honest about ridding us of these folks regardless of whether they can pay or not.)

A similar pathway was recently developed in a tertiary hospital in South Australia with excellent results. Similar principles, social work, case workers, primary care and a defined pathway with rules and management plans individulised. Largely the frequent presenters stopped presenting at all. It was a huge relief to an already under-resourced ambulance service and ED.

We can turn the lights off when we see them coming?

Fliers.

The Washington State limit on ED visits paid for by Medicaid was suspended by that State's Governor, and has not taken effect. There were some legitimate concerns raised by Washington emergency physicians.

As individual nurses, it's not really our job to curb excessive/unnecessary ED visits. I think that, as a society, we need to address the root causes of this, such as lack of access to primary care. I recently read somewhere that the average wait time, nationwide, to see a PCP is 20 days.

I just came to this thread, and I'm so upset right now- I just had a youngish guy come in- CC was ? Kidney stone vs UTI/ possible renal colic- He asked me if he should be seen here in the ED, or wait to 0800 to go to Urgent care, as he didn't have any insurance. I gave him the standard "We can't tell you not to stay" line, and he decided to go to UC. I begged him to make sure he follows up. Next pt. was a FREQUET flier- not quite homeless, but close to it- came in 116 times over the last 12 months- always by ambulance, paid by our tax dollars. Always chronic back pain- just looking for coffee and a turkey sandwich, plus every once in a while he might luck out and get a new provider who doesn't know him, and just might score the Lortab. He routinely gets scripts for Ultram that he throws away on the way out the door. We have to have Security watch him, because he knows his way around the hospital, and will stael anything that isn't nailed down. He goes to the other area hospital as often as he comes to us. HOW IS IT that we as healthcare workers can't report this putz, and get his funding yanked? How is there NOT a cap on costs? If I actually WORK for a living, I can and do have a 1 million dollar insurance cap on my health insurance, but this one person can abuse the system like this? I am looking at him, sitting in registration right now, watching him DEMAND the secretary call him a medicaid cab. I'm so ready to smack him.

I'm so ready to smack him.

:yelclap: Sometimes you wish no one was looking......

I get sick of seeing wasted resources. EMS brings in 'my elbow feel funny' and 'I might be pregnant, either 5 weeks or 5 months, you know, new boyfriends' and 'I have body aches and sniffles and a cough' and you know we pay for it out of our tax dollars. Not to mention 8 ambulances for a population of ~25,000, they really need to pick these people up when there are people dying elsewhere.

I had a guy come in tonight with a sore throat, pain 10/10. This 46 yr old was literally crying (when did adults start acting like kids? Grow the F up). Didn't want to go to his PCP cause "it's too expensive" and no urgent care clinic because "It costs about $200 to walk in the door and get a shot!" I ask, "you know your ED bill will probably be over $1000 dollars right?" He says "oh that's okay."

Common sense is not common......

HOW IS IT that we as healthcare workers can't report this putz, and get his funding yanked?

Because this putz could actually present with a life threatening illness or injury that requires emergency medical intervention.

I know how infuriating these kinds of people are, believe me. But, when we start deciding who deserves medical treatment and who doesn't, we are on a very slippery slope.

What could help with someone like this is to implement a system in your ED where you use care managers to help establish care plans for frequent users of resources. This person's medical record is flagged so that whenever they present, their care plan pops up in the system.

Because this putz could actually present with a life threatening illness or injury that requires emergency medical intervention.

I know how infuriating these kinds of people are, believe me. But, when we start deciding who deserves medical treatment and who doesn't, we are on a very slippery slope.

The problem with the frequent flyers is this - THEY know their cc is BS. 99.9% of the time they aren't there bc they've had a significant change in sxs or they've completed their med regimen and feel no better. That's when it becomes so darn aggravating!!

Ex. - 62yo female in all the time for earache/headache. Seriously, is seen about 5x week for these sxs. Is noncompliant with insulin and bp meds so her bp is always high and sugar requires a lab draw for a value. She can't be seen quickly for the ear pain d/t the bs and bp but all she wants is dilaudid and she knows she won't go to fast track with her VS like they are (and she won't get dilaudid in fast track). She knows she needs ear surgery but said she's "too busy" for it. Grrr.

Then had another pt, 34yo, seen 3x in one 24hr day for sore throat. I walk in the room on the 3rd visit to get history and she had the sound of peritonsillar abscess. Sure enough, that's what it was - iv steroids and abx started asap. She kept saying she hated to bother us over and over. I told her she needed to be seen for that, that's what we're here for, etc. Things could have quickly gone south for her d/t the severe amount of swelling in her throat....

*sigh*

In both cases, my taxes go to help pay for the Medicaid/Medicare and my premiums and copays are high to offset funds the hospital won't collect from those indigent care or nonpayers. But with the latter, my money "feels" better spent.

Honestly? I hear what you are saying, but come on? How about all of the ppl who can't get medical help, becaus ethe funding isn't there, because of people like him?

That's the fallacy. It's not that the funding isn't there because of people like him. There is no cause-effect relationship. Your kidney stone guy isn't eligible for Medicaid because income is not the only criterion for Medicaid eligibility (though I understand that this will change in 2014). The putz is NOT taking anything away from the kidney stone guy. It's the way the system is set up, not the individuals within it, that are responsible for this, just as ED overcrowding isn't the fault of all the people who walk in with the sniffles or a stubbed toe, it is the fault of how the hospitals are choosing to do business.

You're mad at the wrong guy. Yeah, I agree, I would want to smack him too, but the fault really lies at the feet of the CEOs that are making the business decisions. You think they give a rat's ass how many times this putz visits your ED? Of course they don't, his care is reimbursed by Medicaid. They get paid. As far as they're concerned, he's one of your best customers. Your self-pay kidney stone guy? Your CEOs don't give a damn about him either. All they see is dollar signs.

What's criminal to me is how this affects the critically ill who present to the ED, considering tactics such as decreasing bed capacity and short staffing in order to maximize census, cut costs, and maximize profit. The people who are responsible for that, those are the ones *I* want to smack.

I guess this issue is universal... on a similar note but another level - when did it become OK for patients to dictate their own care?? I have been seeing this more and more and I feel like telling the patients "If you're a doctor why don't you treat yourself?" EX: 60 y.o. guy with loooong cardiac history comes in saying "I have chest pain. The morphine will help". Literally. He did not even attempt to beat around the bush!! Then when his labs came back, INR was sub-theraputic, so I told him he will need a Lovenox injection. His response: "oh no! I can't take that! It makes me bruise." Yes, sir. Lovenox is a blood thinner. That is one of the side-effects. "no, my bruising is excessive. Besides, I have been told never to take Lovenox since I have Pulmonary Emboli" Um, if you have PE's Lovenox would actually be very beneficial to you. "No. I won't take Lovenox. I'll take 10mg of Coumadin instead". Um, excuse me?? You'll take???? We're not offering you coumadin because that is not what will help you right now!!! Grrrr. The patients think they know everything about what they need, fight us every step of the way when WE are trying to help THEM!!! And the MD's are such wusses about it. They allow themselves to be walked all over. Of course this guy has been here so many times because we give him whatever he wants. When they called the Tele doc to admit him, the doc didn't even take a history bec as soon as her heard his name he said "oh him again. Just admit him." because you can't very well send home a man who's had MIx3, multiple PE's, Cardiac stents, and complaining of chest pain...