Peter S. Pang, MD, is a site principal investigator for a PCORI-funded project that examines whether patients with acute heart failure who receive patient-centered post-discharge care, including a home visit soon after ED discharge, close outpatient follow-up, and subsequent coaching calls, will have fewer ED revisits and inpatient admissions.

“Most patients who visit the ED don’t require hospitalization. After a careful and thorough evaluation, most are sent home and instructed to follow up with their primary care doctor or specialist,” says Peter S. Pang, MD. Although this sounds simple, some patients are unsure about next steps and therefore are at risk for complications and return ED visits. “By sending patients home with specific support and defined follow-up, we can potentially improve patient outcomes.”

Seeing many patients make repeat visits to the ED inspired Pang, an emergency medicine physician, to consider a more holistic approach to address patient needs. He is part of a multi-site research study led by Sean P. Collins, MD, MSc, which examines whether a patient-centered transitional care intervention can lead to improved outcomes for acute heart failure patients discharged from the ED. Patients randomized to the intervention arm receive focused education and support prior to ED discharge, followed by a home visit, coaching calls, and intensive follow-up. The intervention represents a shift away from traditional brief discharge instructions toward a more comprehensive approach.

Pang notes that social determinants of health are among the most challenging issues to address, especially in the time-compressed environment of a busy ED. “Emergency care is often transactional in nature; a single episode as opposed to a longer-term relationship. By its very design and structure, EDs generally focus on the acute problem, not the chronic one.” Financial stress, transportation barriers, and lack of social, emotional, or caregiver support are among the issues affecting a patient’s outcome when transitioning from the ED to home.    

For Dr. Pang, a valuable insight from the study is the need to dig deeper for the patient’s story underlying the acute presentation. Post-discharge support should ideally be tailored based on each patient’s unique situation and needs. “When we design interventions we think could help, there can be a disconnect between what we think will work and what actually works for each individual patient,” he says. “Having more time to focus on the patient after discharge helps you better understand their circumstances and provide better care.”

Advice for Others

  • Reframe health care challenges (i.e., too many ED visits) as opportunities to participate in the longitudinal care of patients to ultimately improve patient care transitions and outcomes.
  • Design transitional care interventions that leverage the existing healthcare infrastructure, such as emergency services.
  • Recognize that it is not necessary to address all challenges at once to have a measurable impact. “With 130 million emergency department visits per year in the US, a safe and effective intervention that impacts just 1 percent of patients can have a profound impact on those patients’ lives, and on the healthcare system,” Pang says.

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