Project

Case management; emergency department; frequent users; implementation science

Lead
Titre originalImplementing a case management intervention for frequent users of the emergency department: a multicenter study in Switzerland (I-CaM)Recours à la gestion de cas pour décharger les urgencesLa plupart des services d’urgences en Suisse sont surchargés. Les patient-e-s qui recourent aux services d’urgences plus fréquemment que la moyenne expliquent une partie de ce phénomène. L’introduction d’une intervention de type gestion de cas doit pouvoir contribuer à améliorer cette situation.
Lay summary
Portrait / description du projet (projet de recherche en cours)   Cette gestion de cas s’adresse aux patient-e-s usagers fréquents des urgences qui se rendent au minimum cinq fois par année aux secteurs d’urgences. La gestion de cas se réalisera en fonction des hôpitaux avec trois degrés d’intensité : le premier groupe d’hôpitaux bénéficiera d’un soutien fort de type gestion de cas lausannois, le second d’un soutien plus léger et le troisième suivra ses pratiques habituelles. La mise en œuvre de la gestion de cas sera réévaluée dans les trois cas, au travers du recours aux services d’urgences et aux prestations médicales sociales, de la qualité de vie des personnes suivies par les équipes de gestion de cas ainsi que des coûts liés à ces différentes interventions.  Contexte Les services d’urgences en Suisse sont sollicités à l’excès par un petit groupe de patient-e-s. Au sein du centre hospitalier universitaire vaudois, ce groupe bien que ne représentant que 4 % des patient-e-s, génère 12 % des consultations souvent dans le cadre de maladies chroniques, de maladies psychiques associées à des addictions, et d’une complexité socio-économique majeure. Les études réalisées à ce jour montrent que l’introduction d’une intervention de type gestion de cas pour les usagers fréquents des urgences peut contribuer à alléger la surcharge des services d’urgences. Objectif Cette étude vise à l’implémentation de la gestion de cas pour les usagers fréquents des urgences au sein de différentes structures d’urgences. L’objectif est de l’introduire de manière graduelle dans différents hôpitaux de la suisse romande afin d’étudier sa mise en œuvre et ses effets. Importance / Application Un modèle est élaboré qui permet d’éviter le recours excessif aux services d’urgences en Suisse et qui permet de diriger les usagers réguliers souffrant de problèmes de santé complexes vers des offres plus adaptées. Ce modèle peut s’appliquer à tous les services d’urgences de Suisse et ainsi les décharger.

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Last update: 03.10.2017

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Background: Frequent users of the emergency department (ED) and other health care services are of much interest to clinicians, administrators and researchers. Emergency department overuse is linked to ED overcrowding, which in turn has a negative impact on patient and health system outcomes. There are over 1.4 million annual ED visits in Switzerland, with 84% of EDs reporting overcrowding. Frequent ED users made up 4.4% of the patient population and made 12.1% of all visits at the Lausanne University Hospital ED. Driving this high use of health care services is the fact that frequent ED users suffer from chronic medical diseases, including heart disease, pulmonary disease and cancer, at high rates, in addition to mental illness and substance use disorders more commonly associated with frequent ED users. Case management (CM) has been shown to be a cost-effective intervention to reduce ED overuse by frequent users in research settings; however, there is limited knowledge about how to disseminate and implement a CM intervention for ED frequent users on a large scale to diverse clinical settings, including community hospitals and non-academic centers. Aim: The objectives of this project are to: (1) develop and disseminate a practical ‘CM intervention for frequent ED users’ program to several hospitals in the French-speaking region of Switzerland; (2) study the process of implementation of the intervention; and (3) study the impact of the CM intervention on health services outcomes including ED use, health care re-orientation, quality of life and cost. Methods: This project uses a hybrid study design, measuring both health service and implementation outcomes, relating to the dissemination and implementation of a CM intervention program for frequent ED users at multiple sites in French-speaking Switzerland. The interdisciplinary, individualized CM intervention will target frequent users with 5 or more ED visits in the past 12 months. The CM intervention will be modeled on our prior research to provide tailored support to access all necessary somatic and mental health services, substance abuse treatment and social services. All hospitals in the French-speaking region of Switzerland will be eligible to participate in this project. Sites will be randomized into three groups, which will receive different levels of implementation support from the research team (no coaching, non-intensive coaching or intensive coaching). All groups will receive a CM toolkit to assist in the development of CM team and program at their site. The project will be conducted over five phases (Development, Exploration, Preparation, Operation, Sustainability, over a 42-month period, with an additional 6-month period for final analyses (total project duration 48 months). Outcome measures:I. Implementation Outcomes1)Level of Awareness: the number of hospitals contacted divided by the total number of eligible hospitals2)Level of Adoption: the number of sites that decide to adopt the CM intervention divided by the total number of hospitals contacted about the project3)Level of Provision: a)Reach of Intervention (among frequent ED users): total number of frequent users at each site, how many interested in CM, how many use CM services/complete CM intervention b)Fidelity of Implementation: degree to which the CM intervention is implemented as it was originally designed; measured by checklists or by observation (Coach or member of research team during site visits)4)Identifying factors (facilitators and barriers): using existing questionnaires (e.g. Consolidated Framework for Implementation (CFIR) tools) and/or Coach performing semi-structured interviews to elicit factors and offer feedback (Groups 2 & 3)5)Level of Normalization: measure of integration and/or support for intervention (e.g. Normalization Process Theory (NPT) tool)6)Cost assessment of implementation programB. Health Service Outcomes1) Emergency department utilization2) Health care re-orientation: referral to new PCP, medical or mental health specialist, social services3) Quality of life: using WHO-QoL, Euro-QoL4) Cost: hospital-level costs measured Expected benefits and applications: ED services overuse and overcrowding is a critical problem in Switzerland, and this project promotes a highly practical and relevant solution. There is a strong link between chronic disease and frequent ED use, driven largely by the medical and social complexity of these patients. Addressing ED overuse through CM redirects frequent users to more appropriate forms of care, including primary care or substance abuse treatment, while remaining cost-effective. By developing a CM intervention program and studying its implementation at multiple sites, this project will provide insights and lessons for the broader use of CM interventions for health care services overuse throughout Switzerland.