Managing Frequent Fliers: Strategies For Hospitals

Frequent fliers in a healthcare setting are patients who show up repeatedly to a hospital's emergency department. They are also called super-utilizers. These patients have been shown to have more psychiatric, psychosocial, and substance abuse issues than the general population and tend to be complex to manage. Hospitals have started to see more and more frequent fliers, and this has become a big issue. Hospitals are dealing with this problem in different ways, such as referring patients to primary care doctors, social services, mental health and substance abuse programs, and insurance providers. Some hospitals also maintain lists or files of patients with frequent visits to identify them. The use of stigmatizing terminology and icons to identify these patients has been criticized for potentially leading to harmful biases and poor diagnostic judgment.

Hospitals refer frequent fliers to primary care doctors, social services, mental health services, and insurance providers

Hospitals have implemented various strategies to address the issue of "frequent fliers," also known as "super utilizers," who visit the emergency department repeatedly. One effective approach is to refer these patients to primary care doctors, recognizing that some patients do not have a primary care physician and prefer the convenience of the emergency department. Primary care doctors can provide ongoing care and address any underlying issues that may be causing frequent emergency room visits.

Social services play a crucial role in supporting frequent fliers. Hospitals refer these patients to social workers or community resources to address social determinants of health, such as housing instability, food insecurity, or economic difficulties. By connecting patients with the necessary social services, hospitals can help address the root causes of frequent emergency department usage.

Mental health services are also an integral part of managing frequent fliers. Hospitals refer these patients to mental health professionals or substance abuse programs, as many frequent fliers struggle with psychiatric, psychosocial, or substance abuse issues. By addressing mental health concerns, hospitals can provide more holistic care and potentially reduce emergency department visits.

Additionally, hospitals collaborate with insurance providers to coordinate care for frequent fliers effectively. Insurance providers can assist in ensuring that patients have access to the necessary healthcare services and resources, both within and outside of the hospital setting. This coordination aims to improve patient outcomes and reduce unnecessary emergency department utilization.

By adopting these referral strategies, hospitals aim to provide comprehensive care for frequent fliers, addressing their medical, social, and mental health needs. This proactive approach not only benefits the patients but also helps alleviate the strain on emergency departments, improving the overall healthcare system.

Frequent fliers are often stigmatised as super-utilizers and are assumed to misuse emergency departments

The term "frequent fliers" is used to describe patients who are repeatedly admitted to hospital emergency departments. These patients are often labelled as "super-utilizers", implying that they are misusing emergency services. This stigma can lead to negative assumptions and bias from healthcare professionals.

The use of stigmatizing language and iconography in medical records has been criticised by researchers as disrespectful and potentially harmful. They argue that terms like “frequent flyer" and icons designed to identify these patients can create implicit biases and affect the quality of care they receive. For example, a patient with a mental illness may be less likely to receive appropriate medical care if their psychiatric condition overshadows their other health issues.

Some frequent fliers do have complex needs, including psychiatric, psychosocial, and substance abuse issues. They may also suffer from chronic illnesses that require regular hospital visits. However, not all frequent fliers fit this stereotype. In some cases, patients may simply prefer the convenience and accessibility of emergency departments over their primary care physician or may have difficulty accessing consistent care.

The challenge for emergency physicians is to provide appropriate care for these frequent fliers while also addressing the underlying reasons for their repeated visits. In some cases, referring patients to primary care doctors, social services, mental health programs, and insurance providers can help reduce emergency department visits and improve patient outcomes.

Many frequent fliers have psychiatric, psychosocial, and substance abuse issues

"Frequent fliers" or "super utilizers" are patients who show up repeatedly to a hospital's emergency department. They often have psychiatric, psychosocial, and substance abuse issues and tend to be complex to manage. A study from the Agency for Healthcare Research and Quality found that around one-third of a hospital's frequent patients had a history of bipolar disorder, schizophrenia, or psychosis, while almost ten percent of frequent users suffered from drug/alcohol withdrawal, overdose, or intoxication. These patients may also have somatic symptoms, such as chest pain, that are caused by underlying psychological stress or psychiatric illness.

The challenge for emergency physicians is that they are often unable to engage in long conversations about psychosocial stressors or anxiety, which can lead to the underlying causes of a patient's disease being overlooked. The fear of missing a serious illness may also lead physicians to avoid attributing symptoms to psychiatric or psychosocial causes. As a result, patients are often discharged without addressing the root cause of their symptoms, leading to recurrence and repeated visits to the emergency department.

Some hospitals have implemented programs to address the issue of frequent fliers. For example, Sinai Hospital in Maryland identified patients who visited the emergency department four or more times in four months and referred them to primary care doctors, social services, mental health and substance abuse programs, and insurance providers. This approach has been successful in reducing emergency department visits and improving patient care.

While the term "frequent flyer" is commonly used to describe these patients, some researchers argue that this terminology is stigmatizing and can create implicit biases against patients with mental illnesses. The use of icons or labels in healthcare information technology tools to identify frequent fliers has also been criticized for potentially inhibiting good diagnostic judgment and increasing the risk of poor outcomes for patients.

Frequent fliers are more likely to be male, old, socioeconomically deprived, and have comorbidities

"Frequent fliers" in the context of healthcare are patients who show up repeatedly to a hospital's emergency department. These patients are also referred to as "super-utilizers". Frequent fliers are more likely to be male, old, socioeconomically deprived, and have comorbidities.

A study from the Agency for Healthcare Research and Quality found that around one-third of a hospital's frequent patients had a history of bipolar disorder, schizophrenia, or psychosis. Additionally, some patients had suicidal or homicidal ideations. The same study also found that 14.3% of frequent patients across three hospitals did not have a primary care physician, with some patients citing the convenience and accessibility of the emergency department as their reason for preference.

Older adults who visited the emergency department from six to 20 times in a year were considered frequent users. The presence of three or more clinical conditions was associated with a seven times higher likelihood of being a frequent ED user. The most common comorbidity among geriatric patients, regardless of their visit frequency, was diabetes without complications. Other factors linked to frequent ED visits included substance abuse problems and psychiatric diagnoses.

Socioeconomic deprivation is also associated with frequent hospital admissions. A retrospective case series published in PubMed found that across ADI and SVI quartiles, a higher number of comorbidities, decreasing median income, and frailty were associated with increasing deprivation. Interventions to address this issue may include screening of disadvantaged populations and resource allocation to vulnerable neighborhoods.

Frequent fliers can be managed by addressing their underlying psychosocial stressors

"Frequent fliers", or "super utilizers", are patients who repeatedly show up at hospital emergency departments. They are a diverse group of patients, but they tend to have more psychiatric, psychosocial, and substance abuse issues than the general population and are often complex to manage. A study from the Agency for Healthcare Research and Quality found that around one-third of a hospital's frequent patients had a history of bipolar disorder, schizophrenia, or psychosis, while almost 10% suffered from substance abuse issues.

One way to address this issue is to refer frequent fliers to primary care doctors, social services, mental health and substance abuse programs, and insurance providers. For example, Sinai Hospital in Maryland identified 318 people who visited the emergency department four or more times in 4 months and referred them to these services. This project cost the state $800,000 over 3 years but resulted in 1000 fewer emergency department visits and paid for itself. Another patient, Walter, was a "fixture" in the emergency department of a hospital, with chronic health issues and psychiatric illness. He eventually succumbed to his illness, but it was noted that addressing his underlying psychosocial stressors may have improved his quality of life and reduced his frequent visits to the ED.

In addition to improving patient care, addressing the underlying psychosocial stressors of frequent fliers can also reduce the burden on emergency departments. Frequent fliers account for a disproportionate number of admissions and bed days. For example, in 2001-2, frequent fliers represented 14.1% of all patients but accounted for 30.6% of admissions and 35.6% of bed days. By addressing the underlying psychosocial stressors of these patients, hospitals can reduce the number of frequent fliers and improve the efficiency of their emergency departments.

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