Case management in emergency care: impact evaluation of the CARED Program.

Abstract

Background: Hospitals face mounting pressure to reduce unplanned utilization amid rising healthcare demands from an aging population. The Case management for At-Risk patients in the Emergency Department (CARED) program is among the first ED transitional care strategies to focus on both frail older adults and emergency department (ED) re-attenders to reduce acute hospital utilization. This study aims to evaluate the effectiveness of the CARED program in reducing hospital (re)admissions and ED re-attendances within 30- and 60 days post-discharge.

Methods: A retrospective, propensity-matched study was conducted from April 2022 to July 2023 in the ED of Ng Teng Fong General Hospital in Singapore. The CARED program identifies and enrols at-risk patients, i.e. frail older adults and patients who re-attend the ED within 30 days of hospital discharge, for a geriatric assessment. This is followed by multidisciplinary team care, discharge planning and right siting of care from the ED to community-based services by ED case managers. The primary outcomes were hospital (re)admissions and ED re-attendances within 30- and 60 days post-discharge. Secondary outcomes were cost avoidance and bed occupancy days from reduced acute hospital usage.

Results: Nearest-neighbour 1:1 propensity score matching matched 1615 intervention group to 1615 control group. Baseline characteristics of the intervention and control groups did not differ significantly. Difference-in-differences (DID) analyses showed significantly lower 30-day (3.96%; 95% CI 2.71-5.23%) and 60-day (6.69%; 95% CI 5.47-7.91%) hospital admissions, as well as 30-day (4.89%; 95% CI 3.83-5.95%) and 60-day (6.50%; 95% CI 5.28-7.72%) ED re-attendances in the intervention group compared to the control group. Additionally, the reduced admission and ED re-attendance rates resulted in 30-day and 60-day inpatient admission costs avoidance [$1 553 548.96 (69.86%); 95% CI $1 525 827.76 to $1 581 270.15; P = .006; and $1 400 047.07 (32.56%); 95% CI $1 365 484.79 to $1434 609.37; P = .048, respectively], ED attendance costs avoidance [$25 849.92 (23.70%); 95% CI $25 091.93 to $26 607.89; P = .096; and $37 538.39 (18.09%); 95% CI $36 470.27 to $38 606.53; P = .086, respectively] and bed occupancy days saved (1212 days; 95% CI 1191.80 days to 1232.20 days; P = .003; and 1267 days; 95% CI 1242.58 days to 1291.42 days; P = .011, respectively).

Conclusion: CARED program effectively reduced unplanned hospital use within 30- and 60 days post-ED discharge for at-risk patients. It also significantly lowered inpatient admission and ED attendance costs and hospital bed occupancy days, highlighting its potential to improve patient outcomes and reduce healthcare expenses.