Detroit Medical Center and Vanguard Health have won a $9,966,608 Department of Health an Human Services (HHS) Health Care Innovation Award to test what might happen to emergency department utilization if patient-centered medical home clinics are established next to four major inner-city emergency departments (EDs) and used to make primary care immediately available to individuals who arrive at the EDs for non-urgent care.

A concern with health care coverage expansion is that it could lead to more ER overutilization if the newly insured continue to turn to ERs for primary care needs because of access barriers, including simple lack of knowledge about how to find a primary care doctor open to new patients. And indeed, that is exactly what happened in Oregon according to a study of ED use in the state after Medicaid was expanded. Contrary to the conventional wisdom that costly ED visits for non-urgent care would drop after more residents could enroll in Medicaid, the visits actually went up instead.

(Nationally, the Robert Wood Johnson Foundation just announced that it was starting a new initiative with to collects data each quarter on all inpatient admissions and ED visits by payer in 24 participating states to monitor the impact of health reform on healthcare utilization, including ED visits.)

The initial focus of the Detroit Medical Center test will be on improving the care provided to patients with diabetes or asthma, as well as ED “super-utilizers,” defined as patients with 10 or more ED visits per year. The main target patient population will be Medicaid fee-for-service beneficiaries.

After the program is a little more established, plans call for it expanding to include patients with the comparatively more complicated problems of hypertension, congestive heart failure, chronic obstructive pulmonary disease, HIV and depression.

The goal is not to simply deliver the same non-urgent condition care that would have been delivered in the ED, but to deliver a better type of care that is focused on wellness and keeping the patient from needed to come back again and again for more care.

According to the proposal description, the project is designed to replicate elements of the Nuka model pioneered by the Anchorage, Alaska, Southcentral Foundation healthcare system. Nuka, an Alaska Native word, describes a team-based system of caring for patients that prioritizes achieving physical, mental, emotional, and spiritual wellness in order to help patients improve their quality of life, as well as a sincere effort to build personal relationships among providers, staff, patients, and the surrounding community.  

In the Detroit test project, the team-based interaction with the patient will consist of face-to-face visits, telephone contact and texting. Services will include an initial assessment of patient expectations, screening for depression, and active engagement of patients in their disease management.

The primary care medical homes also will use coaches and navigators to help patients get to the point of self-managing their disease, with the ultimate goal of both improving quality of life and reducing ED service costs.

The innovation award was part of the second round of HHS’s Innovation grants. All total, $360 million was handed out to 39 recipients spanning 27 states and the District of Columbia.

Other awards went for improving emergency care, care for children, cardiovascular disease management, rural care coordination and telehealth, care for the frail elderly, and care for persons living with HIV/AIDS. However, no other award targets as directly the issue of ED use and primary care access.

The Detroit Medical Center operates DMC Children’s Hospital of Michigan with nine specialties centers, DMC Detroit Receiving Hospital, DMC Harper University Hospital, DMC Huron Valley-Sinai Hospital, DMC Hutzel Women’s Hospital, DMC Rehabilitation Institute of Michigan with more than 30 outpatient locations, DMC Sinai-Grace Hospital, and DMC Surgery Hospital.