Evaluation of the use of individualized patient care plans in frequent emergency department visitors with pain complaints

Abstract

Background Pain is one of the most common complaints that patients present to the emergency department for; emergency medicine providers are tasked with providing appropriate pain relief while simultaneously limiting the risk of personal and societal harm that may result from opioid misuse. The Lakeland Regional Medical Center developed a medical management program that identified frequent emergency department visitors with a chief complaint of pain. Individualized care plans were developed for these patients. A retrospective review was then conducted to assess the efficacy of these care plans in reducing the number of emergency department visits for pain-related complaints by the patients entered into the medical management program. Results There were 294 patients; 65% were male, and the median age was 41 (interquartile range: 33 to 51). A total of 80% percent of the patients were white, and the payors were as follows: 53% were self-pay, 42% were government programs, and 5% had private insurance. The three most common chronic pain complaints were 39% abdominal pain, 24% back/neck pain, and 23% headache/migraine (patients could have more than one area of pain). A total of 60% of the patients had a primary care provider, and another 18% had a pain management provider in addition to primary care. Post plan admissions were significantly reduced to a median of 1 (IQR 0 to 3) with the Wilcoxon signed-rank test’s p-value of less than 0.001. Conclusion The authors describe their experience with a quality improvement initiative that identifies frequent emergency department visitors with a chief complaint of pain and provides individualized care plans to these patients. The goals of the program are to improve patient’s quality and consistency of care, through interventions that eliminate the prescribing of opioids while providing non-opioid alternatives.

A mapping review of interventions to address patients who frequently seek care in the emergency department

“…Study population size varied widely, ranging from seven participants to over 100,000. Fifteen studies had a study population of less than 100 [ 14 , 26 , 30 , 34 , 36 , 41 , 44 , 47 , 51 , 57 , 62 , 65 , 66 , 68 , 71 ], 24 had a study population of 100–500 [ 15 , 16 , 27 , 28 , 32 , 33 , 38 , 40 , 42 , 43 , 48 – 50 , 53 , 55 , 58 – 61 , 63 , 67 , 72 , 77 , 79 ], six had a study population of 500–1,000 [ 31 , 45 , 64 , 74 , 78 , 80 ], and 13 had a study population of more than 1,000 [ 18 , 29 , 36 , 37 , 39 , 46 , 52 , 54 , 56 , 69 , 70 , 75 , 76 ], Fig. 2 .…”

“…In the literature search, the only interventions developed based on patients’ demographic characteristics were interventions for older adults, of which there were 16 studies [ 18 , 27 , 29 , 35 , 36 , 40 , 45 , 54 , 56 , 67 , 69 , 72 , 74 – 76 , 78 ]. For patient health and disability status, 12 studies were for those with chronic conditions such as diabetes, chronic pain, or epilepsy [ 31 , 33 , 34 , 37 , 38 , 53 , 58 , 60 – 62 , 66 , 73 ], six for those with substance use disorders [ 26 , 43 , 48 , 50 , 52 , 59 ], three for those with mental health conditions [ 30 , 46 , 63 ], and one for people with a disability [ 71 ]. Last, there were four studies developed based on patients’ social factors, three for those with social and material deprivation [ 32 , 44 , 51 ] and one for people experiencing homelessness [ 57 ], Table 1 .…”

“…Several interventions were utilized in the literature, and many studies reported multi-faceted interventions, Table 1 . Overall, 36 studies reported on continuation of care interventions: 12 reported on care plans [ 15 , 26 , 28 , 30 , 38 , 41 , 42 , 45 , 49 , 68 , 70 , 75 ], nine reported on case management [ 14 , 15 , 44 , 47 , 55 , 63 , 64 , 72 , 79 ], eight reported on care coordination [ 16 , 39 , 48 , 50 , 58 , 65 , 69 , 77 ], six reported on follow-up phone calls [ 18 , 30 , 35 , 36 , 60 , 67 ], and one reported on a care transition intervention [ 51 ]. Seventeen interventions reported on additional services in the ED: four each reported on education [ 34 , 45 , 61 , 67 ] and geriatric assessment [ 72 , 75 , 76 , 78 ], two each reported on physical therapy services [ 27 , 29 ], specialist consultations [ 31 , 76 ], and medication review [ 27 , 74 ], and one each reported on early assessment and intervention [ 40 ], counselling [ 60 ], and telepsychiatry [ 46 ].…”