Article

Transitional care clinics for follow-up and primary care linkage for patients discharged from the ED

a b s t r a c t

Objectives: Transitional care clinics (TCCs) represent one strategy to facilitate follow-up and primary care linkage for patients with no regular source of care who are discharged from the emergency department (ED). We assessed factors associated with completion of TCC follow-up among these patients and characterized their subsequent ED use.

Methods: Retrospective study of 660 randomly sampled patients with a scheduled appointment to a TCC at time of ED discharge. Patient- and visit-level characteristics were abstracted from the medical records of these patients and linked to a state visit database to characterize ED use after referral. Multiple logistic regression was used to determine factors associated with completion of follow-up and subsequent ED utilization.

Results: Half (50%) of the patients completed their follow-up appointment with a mean follow-up time of 6.9 days. Non-English language (odds ratio [OR], 2.21; confidence interval [CI], 1.30-3.75) was the only factor associated with improved follow-up; however, patients who were homeless (OR, 0.42; CI, 0.26-0.66) had a substance use history (OR, 0.68; CI, 0.45-1.00), and those with more baseline ED visits (OR, 0.94 per additional ED visit; CI, 0.89-0.99) were significantly less likely to complete follow-up. After adjusting for demographic, clinical, and visit-level characteristics, patients who completed their appointment had significantly fewer ED visits in the subsequent year compared to patients who did not complete their appointment (mean, 2.3 vs 3.3 visits; difference, -1.0 visits in subsequent calendar year; CI for difference, -1.2 to -0.7).

Conclusion: Transitional care clinics represent a promising strategy to improve the continuity of care for emergency patients and may reduce unnecessary ED use.

Introduction

Ensuring timely follow-up for patients discharged from the emergency department (ED) is a major component of effective Care coordination for patients with acute illnesses [1]. Inadequate transitions of care in the acute setting contribute to poor patient compliance with recommended therapy and follow-up [2], unnecessary ED utilization for nonurgent needs [3], and increased rates of unschedulED revisits [4-6]. The Institute of Medicine has identified care coordination improvements as a priority for the improving the efficiency and efficacy of the health care system [7].

? This research project was funded by grant 1K12 HS022982-01 of the Agency for Healthcare Research and Quality patient centered outcomes Research Institutional Mentored Career Development Program (K12).

* Corresponding author at: Division of Emergency Medicine, Harborview Medical Center, 325 9th Avenue, Box 359702, Seattle, WA 98104. Tel.: +1 206 744 6005 (direct);

fax: +1 206 744 4095.

E-mail addresses: [email protected] (K. Elliott), [email protected] (J. W. Klein), [email protected] (A. Basu), [email protected] (A.K. Sabbatini).

Previous studies have indicated follow-up compliance after an ED visit is generally low. Often, inability to secure a timely follow-up ap- pointment is a significant, if not the primary barrier for many patients, particularly those without insurance [1,8,9]. For example, as many as one- to two-thirds of patients who attempt to make appointments with a primary care provider after the ED visit are unable to obtain a timely follow-up appointment, depending on their insurance coverage and availability of primary care resources [8]. However, ED-level inter- ventions that facilitate follow-up through set appointments, reminder calls, or other more intensive Case management have demonstrated increase in rates of follow-up compliance [10] and improvements in future primary care usage [11].

Transitional care clinics (TCCs) (also called postdischarge clinics) offer one solution to meet the time-sensitive, Acute care needs of patients discharged from the ED. These clinics have been used effective- ly by hospitals to facilitate safe transitions of care after patients are discharged from an inpatient stay [12,13]. In the ED setting, TCCs pro- vide a mechanism to follow-up on patients’ acute care needs while also linking patients who use the ED as a their predominant source of care with other primary care resources.

http://dx.doi.org/10.1016/j.ajem.2016.03.029 0735-6757/

The Harborview Medical Center After Care Clinic (ACC) is a TCC established in 2008 to provide follow-up for Harborview Medical Center medically unaffiliated patients discharged from the ED, hospital, or spe- cialty clinics and seeks to bridge their transition to primary care. Major goals of the ACC are to reduce avoidable Hospital readmissions and min- imize the use of the ED for clinic-level care. Importantly, for emergency patients, all appointments are scheduled at the time of ED discharge, which has been shown to improve follow-up compliance [2,14-18].

The goal of this study is to assess the patient and clinic-level characteristics associated with completion of follow-up among patients referred to the ACC at time of ED discharge. We also sought to characterize the subsequent ED utilization of patients who completed their ACC appointment vs those who did not, as ED utilization may be an indicator of the ability of the ACC to link patients with an alternative source of care.

Materials and methods

Study design and setting

We performed a retrospective study of ED patients who received a referral to the ACC at Harborview Medical Center (Seatle, WA) between the months of September 2013 to August 2014. Harborview Medical Center is a 413-bed, tertiary care center and teaching hospital owned by King County. The ED has approximately 64, 000 visits per year and serves a high proportion of vulnerable patients including immigrants, homeless, and the uninsured, with a high proportion of patients having no relationship with a primary care provider. The ACC serves as a bridge to primary care for patients discharged from the Harborview Medical Center ED. After discussion with the patient, the ED provider sets an ACC appointment for those who state they do not have an active rela- tionship with a primary care provider/clinic and who either require re-evaluation for their acute condition or who wish to establish care with a primary provider. Patients are provided with a printed copy of their appointment information with their discharge paperwork. Generally, ACC appointments are obtainable within 4 to 8 days of the ED visit, although earlier appointments are sometimes available. At the time of their follow-up, ACC staff work with patients to determine their preferences for primary care and locate an appropriate provider convenient for the patient. Patients are generally given another scheduled appointment with their chosen provider at the time they leave the ACC. The institutional review board of the University of Washington Medical School approved the study protocol.

Cohort selection

All patients who received a referral to the ACC at time of ED discharge within the 12-month study period were eligible for inclusion in our study (N = 2438). We randomly sampled 660 of these referrals for full electronic medical record abstraction to identify predictors of completion of follow-up and characterize the effect of the ACC on subsequent ED utilization.

Outcomes

Our primary outcome was whether the patient completed follow-up in the ACC as scheduled at the time of ED discharge. A follow-up ap- pointment was considered successful if the visit status was listed as “Completed,” and the patient had a corresponding clinic note in their chart. Patients who canceled their initial appointment but were eventu- ally seen at a rescheduled visit were considered to have completed their ACC appointment. Patients listed as either “No Show” or “Canceled” without a clear reschedule in the medical chart were considered to have failed to complete follow-up. Secondary outcomes included ED uti- lization in the year after ACC referral among patients who completed their appointment vs those who did not.

Variables

We used patient demographic information, clinical characteristics, and encounter-level characteristics abstracted from the medical record as potential predictors in our assessment of follow-up completion. Data elements were abstracted by a trained research assistant (KE). A random sample of 20% of these abstracted charts was reviewed by a second mem- ber of the study team for accuracy (AKS). Patient characteristics included age, sex, race, marital status (dichotomized as married vs all other status- es), language (dichotomized as non-English primary language vs English speaking), comorbid illness (chronic pain: dichotomized as yes/no for history of chronic pain; and Elixhauser comorbidities [19], dichotomized as >= 2 vs 0-1 comorbidities), and primary payer at time of ED visit. Encounter-level characteristics included admission source (emergency medical services [EMS] vs walk-in), triage acuity (Emergency Severity Index [ESI] [20]), triage vital signs (dichotomized as any abnormal vital sign vs normal), ED discharge diagnoses, length of stay in minutes, and number of days to ACC follow-up appointment. To group discharge diag- noses into Clinically meaningful categories, we used Clinical Classification Codes [21] from the Agency for Healthcare Research and Quality. Dis- charge diagnoses were then ranked by the top 10 most common dis- charge diagnoses for the cohort. We combined diagnoses that qualified as minor injuries (superficial injury, contusion, or sprains and strains) into a single category. Outpatient clinic notes were examined to deter- mine completion of follow-up and characterize the proportion of patients who received appointments with a primary care provider from the ACC. Lastly, we also examined ED utilization among patients who com- pleted their ACC visit vs those who did not. We linked data abstracted from the Harborview Medical Center medical record to data in the Washington state Information Exchange System, which is a state- sponsored database that tracks all ED visits for individual patients to EDs in Washington State. We counted baseline ED use (defined as the number of visits in the year before ACC referral) and all subsequent visits in the year following ACC referral. Subsequent ED utilization was characterized in 3 ways: (1) the average number of ED visits per patient within 1 year of ACC referral, (2) the proportion of patients with any ED re-visit within 30 days of ACC referral (short-term revisits), (3) and the proportion of patients with any ED revisit within 1 year of ACC referral. Subsequent ED utilization was examined for patients with high baseline ED use, defined as greater than or equal to 5 ED visits in the year preced-

ing referral, vs those who had less than 5 visits.

Primary data analysis

Descriptive statistics were generated for the study cohort and were stratified by completion of ACC appointment. Bivariate analyses were conducted using t tests for continuous variables and ?2 test for categor- ical variables. We conducted two separate regression analyses. We first examined the demographic, clinical, and visit-level characteristics asso- ciated with completion of follow-up in the ACC using multivariate logis- tic regression with the candidate predictors. We then used these same predictors, along with the patient’s ACC completion status, to examine adjusted ED revisit rates in the year after ACC referral. Given that many patients had no ED revisits, we used a multivariate Poisson re- gression model to examine counts of subsequent revisits in the year after ACC referral. In addition, logistic regression models were used to examine the proportion of patients who had any revisit within 30 days or 1 year of ACC referral. Statistical analyses were completed with Stata MP (version 13; StataCorp).

Results

Characteristics of sample

Table 1 describes the patient-level and encounter-level characteris- tics of our study cohort, stratified by whether the patient completed

Table 1

Characteristics of patients receiving referrals to the ACC from the ED, stratified by completion of follow-up a, b, c

All ACC referrals, n = 660

No show/canceled, n = 330 (50.0%)

Completed, n = 330 (50.0%)

P

Patient characteristics

Age (%)

16-39 y

310 (47.0)

164 (49.7)

146 (44.2)

.33

40-64 y

309 (46.8)

145 (43.9)

164 (49.7)

>= 65 y

41 (6.2)

21 (6.4)

20 (6.1)

Female (%)

216 (32.7)

103 (31.2)

113 (34.2)

.41

Race (%)

White/non-Hispanic

271 (41.1)

151 (45.8)

120 (36.4)

.002*

Black/non-Hispanic

199 (30.2)

86 (26.1)

113 (34.2)

Hispanic/Latino

84 (12.7)

37 (11.2)

47 (14.2)

Asian/Pacific Islander

54 (8.2)

21 (6.4)

33 (10.0)

Other/unknown

52 (7.9)

35 (10.6)

17 (5.2)

Non-English language (%)

139 (21.1)

44 (13.3)

95 (28.8)

b.001*

>= 2 comorbiditiesa (%)

135 (20.5)

81 (24.6)

54 (16.4)

.009*

Chronic pain (%)

104 (15.8)

47 (14.2)

57 (17.3)

.29

Primary payer (%)

Private

73 (11.1)

45 (13.6)

28 (8.5)

.005*

Medicare

58 (8.8)

35 (10.6)

23 (7.0)

Medicaid

218 (33.0)

117 (35.5)

101 (30.6)

Uninsured

263 (39.9)

115 (34.9)

148 (44.9)

Otherb

48 (7.3)

18 (5.5)

30 (9.1)

ED visits in prior year (n), mean (SD)

2.2 (5.3)

3.1 (6.8)

1.3 (3.0)

b.001*

Married (%)

159 (24.1)

70 (21.2)

89 (27.0)

.08

Homeless (%)

135 (20.5)

96 (29.1)

39 (11.8)

b.001*

Psychiatric diagnosis (%)

79 (12.0)

46 (13.9)

33 (10.0)

.12

Substance use (%)

235 (35.6)

148 (44.9)

87 (26.4)

b.001*

Encounter characteristics

Triage acuity (%)

ESI level 2

51 (7.7)

29 (8.8)

22 (6.7)

.26

ESI level 3

438 (66.4)

226 (68.5)

212 (64.2)

ESI level 4

152 (23.0)

67 (20.3)

85 (25.8)

ESI level 5

19 (2.9)

8 (2.4)

11 (3.3)

EMS arrival (%)

95 (14.4)

53 (16.1)

42 (12.7)

.22

Any abnormal vital sign (%)

233 (35.3)

130 (39.4)

103 (31.2)

.03*

ED LOS, min, mean (SD)

293 (403)

320 (553)

266 (134)

.09

ED discharge diagnosisc (%)

Minor injuries

86 (13.0)

45 (13.6)

41 (12.5)

.92

soft tissue infections

67 (10.2)

35 (10.6)

32 (9.7)

Abdominal pain

42 (6.4)

21 (6.4)

21 (6.4)

Back pain

36 (5.5)

20 (6.1)

16 (4.9)

Nonspecific chest pain

28 (4.2)

14 (4.2)

14 (4.2)

Hypertension

16 (2.4)

5 (1.5)

11 (3.3)

Nontraumatic joint disorders

15 (2.3)

6 (1.8)

9 (2.7)

Headache

14 (2.1)

7 (2.1)

7 (2.7)

Asthma

14 (2.1)

8 (2.4)

6 (2.1)

upper respiratory infection

13 (2.0)

7 (2.1)

6 (1.8)

Other diagnoses

329 (49.9)

162 (49.1)

167 (50.6)

Days to follow-up appt., mean (SD)

6.9 (4.1)

7.0 (3.1)

6.9 (4.9)

.71

Subsequent ED utilization

Mean ED visits per patient in subsequent year

3.1

4.3

1.9

b.001*

Any revisit within 30 d (%)

157 (23.8)

98 (29.7)

59 (17.9)

b.001*

Any revisit within 1 y (%)

370 (56.1)

205 (62.1)

165 (50.0)

.002*

a Number of Elixhauser comorbidities.

b Other payers include labor and industries and auto insurance claims.

c Top 10 most common diagnoses.

their ACC follow-up appointment. Among the 660 patients in our co- hort, exactly 50% (n = 330) completed follow-up in the ACC with a mean time to follow-up appointment of 6.9 days. The mean age was

41.8 years, and approximately a third of the referrals were female (32.7%). Most patients were white/non-Hispanic (41.1%), uninsured (39.9%), and presented for low-moderate acuity complaints (triaged as ESI level 3 [66.4%] or level 4 [23.0%]). The most common discharge di- agnoses of patients referred to the ACC were minor injuries, soft tissue infections, abdominal pain, back pain, and nonspecific chest pain. More than half (54.9%) of patients had no prior visits in the preceding year, and another 14.9% had 1 visit. Only, 17.6% met criteria for high baseline ED use (5 or more visits in 1 calendar year).

In bivariate analyses, nonwhite race, patients who spoke a primary language other than English, and those who were uninsured or had

other forms of insurance (such as auto claims and labor and industries) were significantly more likely to complete follow-up when referred. Conversely, patient with higher baseline ED utilization (more ED visits in the year before referral), Homeless patients, or those with substance use histories were significantly less likely to complete their scheduled follow-up.

Predictors of follow-up

In our multivariable model, few Sociodemographic variables and none of the ED visit-level characteristics predicted which patients would complete their scheduled follow-up. Non-English language (odds ratio [OR], 2.21; confidence interval [CI], 1.30-3.75) was the only variable that remained significantly and strongly associated with

Table 2

Predictors of follow-up completion among patients referred to the ACC at time of ED discharge

OR 95% CI P

Age

16-39 y

Ref

Ref

40-64 y

1.34

0.94-1.92

.10

>= 65 y

1.09

0.52-2.27

.83

Female

Race

0.95

0.65-1.38

.81

White/non-Hispanic

Ref

Ref

Black/non-Hispanic

1.08

0.71-1.62

.72

Hispanic/Latino

0.76

0.41-1.44

.41

Asian/Pacific Islander

0.96

0.49-1.90

.92

Other/unknown

0.50

0.26-0.95

.03*

Non-English Language

2.21

1.30-3.75

.003*

>= 2 comorbidities

1.02

0.60-1.71

.95

Chronic pain

Primary payer

1.30

0.82-2.04

.26

Private

Ref

Medicare

1.14

0.50-2.61

.76

Medicaid

1.40

0.77-2.53

.28

Uninsured

1.59

0.88-2.86

.12

Other

2.20

0.97-4.99

.06*

ED visits in prior year

0.94

0.89-0.99

.03*

Married

0.79

0.50-2.61

.76

Homeless

0.42

0.26-0.66

b.001*

Psychiatric diagnosis

1.64

0.86-3.15

.13

Substance use

0.68

0.45-1.00

.05*

Triage acuity

ESI level 2

Ref

Ref

ESI level 3

1.00

0.53-1.89

.99

ESI level 4

1.34

0.65-2.77

.42

ESI level 5

1.33

0.42-4.17

.62

EMS arrival

1.06

0.64-1.76

.81

Any abnormal vital sign

0.89

0.65-1.76

.81

ED LOS, per 60 min

0.99

0.97-1.00

.14

injury diagnosis (vs medical)

0.97

0.62-1.51

.89

Days to follow-up appt.

1.01

0.96-1.05

.71

Abbreviation: LOS, length of stay.

completion of follow-up (Table 2). However, homeless patients (OR, 0.42; CI, 0.26-0.66), those with a history of substance use (OR, 0.68; CI, 0.45-1.00), and those with more ED visits in the year preceding referral (OR, 0.94 for every additional ED visit; CI, 0.89-0.99) were significantly less likely to complete follow-up. Importantly, the number of days between the ED visit and follow-up appointment was not significantly associated with completion of follow-up.

Subsequent ED utilization and primary care referral

Overall, there were on average 3.1 ED visits per patient in the subse- quent year after ACC referral, with 23.8% having a revisit within 30 days and 56.1% having any revisit in the subsequent year (Table 1). Among the 330 patients who completed their ACC appointment, 244 (73.9%) received another appointment to primary care medical homes during their ACC appointment. Table 3 describes adjusted rates of ED utilization after referral to the ACC, stratified by completion of their ACC appointment. After adjusting for demographic, clinical, and visit-level characteristics, patients who completed their ACC appointment had sig- nificantly fewer ED revisits in the subsequent year compared to patients who did not complete their ACC appointment, with an average of 2.4 vs

3.3 ED revisits (difference, – 1.0 visit in subsequent year; CI for difference, -1.2 to -0.7; P b .001), respectively. However, when ED utilization was expressed as a dichotomous outcome, there were no sig- nificant differences in the proportion of patients who had any ED revisit within 30 days or 1 year.

The effect of completing an ACC appointment on Subsequent ED visits differed among patients with high baseline ED utilization vs those with lower ED utilization (Table 4). Patients meeting our criteria as high ED users (5 or more ED visits in the year preceding ACC referral) that completed their ACC appointment when referred had significantly fewer ED visits in the subsequent 1 year, with an average of 7.0 vs 10.9 (difference of -4.0 visits; CI, -5.3 to -2.6; P b .001) visits per person. These differences were not observed for patients with lower baseline ED utilization.

Discussion

In this retrospective study, we assessed the patient- and visit-level factors predicting completion of follow-up among a cohort of patients who were provided with scheduled appointments for a TCC (the Harborview Medical Center ACC) at time of ED discharge. Exactly half of the patients who received appointments to the ACC completed their follow-up, which is within the range reported in prior studies of facili- tated follow-up after an ED visit [2,14,15,17,18,22]. Although nonwhite minorities, Uninsured patients and those who spoke languages other than English were more likely to complete follow-up in our unadjusted analyses, the only factor that was significantly predicted completion of follow-up in our multivariable model was non-English language. However, we also found that patients who were homeless, had a history of substance use, and had higher baseline rates of ED use in the year pre- ceding ACC referral were significantly less likely to complete follow-up. Although we only identified a few factors that predicted follow-up completion, whether a patient completed their follow-up had implica- tions for subsequent ED utilization. Specifically, patients who completed their appointment had fewer total visits in the year after ACC referral, with an average of one less ED visit per patient after adjusting for demo- graphic and clinical characteristics. This translates to approximately 50 fewer ED visits for every 100 patients who were provided an appoint- ment to the ACC at time of ED discharge. Notably, although patients with high baseline ED use continued to have high rates of ED visits in the year after ACC referral, those who completed their scheduled ap- pointment had approximately 36% fewer revisits in the subsequent year compared with those who did not (or approximately 195 fewer

ED visits for every 100 high ED users referred).

A major barrier to safe discharge of ED patients is the ability to se- cure timely follow-up. Several studies show that patients have difficulty securing follow-up appointments soon after the ED visit [8,23,24]. Pri- mary care clinics continue to be crowded and have little availability to provide last minute appointments [25]. Patients may also be unwilling to take additional time off of work after they already spent a day in the ED, and few clinics offer evening and weekend hours [26]. For self- limited conditions such as an upper respiratory infection or headache, a longer time to follow-up is likely appropriate and safe. However, pa- tients with injuries, such as back pain from a herniated disk, accelerated hypertension, or soft tissue infections (all common diagnoses in our re- ferral cohort), should ideally be re-evaluated shortly after their ED visit,

Table 3

Adjusted rates of ED utilization after ACC referral stratified by completion of ACCa

No show/canceled, n = 330 (50.0%)

Completed, n = 330 (50.0%)

Difference

P

Mean ED visits per patient in subsequent year

3.3 (3.1-3.5)

2.4 (2.2-2.6)

-1.0 (-1.2 to -0.7)

b.001a

Any revisit within 30 d

25.3% (20.9-29.8)

20.4% (16.1-24.7)

-4.9% (-11.3 to 1.6)

.14

Any revisit within 1 y (%)

54.9% (49.9-60.0)

55.4% (50.7-60.0)

-0.5% (-6.6 to 7.5)

.94

a Rates of ED utilization adjusted for all patient and encounter level predictors.

Table 4 Adjusted rates of ED utilization after ACC referral, stratified by ED utilization (high baseline ED utilization [>=5 ED visits in year preceding referral] vs lower baseline ED utilization [b5 visits in year preceding referral])

No show/canceled

Completed

Difference

P

High ED users, n (%) 76 (65.5)

40 (34.5)

Mean ED visits per patient in subsequent year 10.9 (10.1-11.7)

7.0 (6.0-7.9)

-4.0 (-5.3 to -2.6)

b.001

Lower ED users, n (%) 254 (46.7)

290 (53.3)

Mean ED visits per patient in subsequent year 1.6 (1.4-1.7)

1.5 (1.3-1.7)

-0.08 (-0.3 to 0.2)

.52

as their risk for complications, continued symptoms, or preventable ED revisits is high.

Transitional care clinics, such as the ACC, represent one solution for improving access to follow-up care and reducing potentially unneces- sary ED visits among patients without a usual source of care. However, there are also inefficiencies with this strategy. In our study, many ACC appointment slots went unused, which represents a missed opportunity for other patients who would successfully complete appointments and limits the ability of the ACC to provide rapid (48-72 hours) re- evaluation of patients. Our results would suggest that merely providing scheduled appointments for those who are unlikely to follow-up (such as homeless patients or those with history of substance use) is an inadequate solution. More intensive care coordination or other targeted interventions may be necessary to improve follow-up rates for these patients [10]. As a result, further studies examining the effectiveness of TCCs on ED utilization and primary care linkage are necessary.

Limitations

Our study has several limitations. First, our ED is a large safety net hospital that treats a high proportion of vulnerable patients. As a result, our findings are not generalizable to EDs with a significantly different patient population. Second, one of the stated goals of the ACC is to link patients without a usual source of care to primary care homes. However, our retrospective design did not permit us to follow up patients who were referred to a primary provider from the ACC, to see whether they actually established care with a medical home. Many of these patients were referred to primary providers outside of the Harborview Medical Center and University of Washington system. As a result, we were unable to directly assess the full utility of the TCC on facilitating primary care linkage. We hypothesize that the reason for differences in subsequent rates of ED utilization between those who completed follow-up and those who did not is because many of these patients were appropriately linked with a primary care provider and, therefore, had an alternative source of care other than the ED when future needs arose. However, our examination of subsequent ED utilization is a de- scriptive analysis and is not designed to control for all confounders. In addition, we could not assess whether the patient obtained follow-up from another non-ED source. The Information Exchange System allows for complete capture of ED visits within the State of Washington but will not capture visits to out-of-state EDs, which may also affect revisit rates. Finally, we may not have found many significant predictors of follow-up in our multivariate model due to our relatively small sample. An evalu- ation of all patients referred to the ACC during the same period of time (N = 2438) may have been more informative, but we would not have been able to manually abstract the data in detail for all these patients.

Conclusion

As more attention focuses on improving transitions of care in the acute setting, EDs will need to develop unique methods to facilitate timely follow-up after an ED visit and link patients with primary care homes. The availability of resources such as a TCC may serve to bridge the health care gaps between acute care delivered in the ED and primary care. Understanding how to target this resource to those patients most likely to benefit may improve the continuity of care for emergency

patients at risk for poor outcomes and lead to the reduction of unneces- sary ED use.

Acknowledgments

This research project was funded by grant 1K12 HS022982-01 of the Agency for Healthcare Research and Quality Patient Centered Outcomes Research Institutional Mentored Career Development Program (K12).

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