ED utilization among our client’s Medicare Advantage members exceeded 400 visits per 1,000, creating significant cost pressures, avoidable utilization, and fragmented care transitions under global risk. High ED use also reflected gaps in access, limited real-time visibility into patient encounters, and inconsistent follow-up with primary care providers—making it difficult to manage patient needs proactively and reduce unnecessary emergency visits.
Reducing Avoidable ED Utilization Through Real-Time Transitions-of-Care for Medicare Advantage Members
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- Reducing Avoidable ED Utilization Through Real-Time Transitions-of-Care for Medicare Advantage Members
Emergency Department (ED) utilization is one of the most sensitive drivers of total cost of care and a key indicator of access, care coordination, and performance in value-based arrangements. For Medicare Advantage populations—especially under global risk—avoidable ED visits can escalate spend, fragment care, and create downstream challenges for primary care providers and care management teams.
This case study highlights how our real-time ED Transitions-of-Care model gave organizations immediate visibility into member encounters, enabled proactive outreach, and strengthened follow-up with primary care teams. By integrating ADT notifications, coordinated care management, and omni-channel engagement, we helped reduce unnecessary ED utilization and improve clinical and financial outcomes under global risk.
Challenge
Solution
We implemented a real-time ED Transitions-of-Care program built around Admission, Discharge, and Transfer (ADT) notifications to ensure immediate visibility into member encounters. Our approach included rapid care management outreach, streamlined communication with primary care providers, standardized follow-up protocols, and coordinated omni-channel engagement to support patients after ED visits. This model improved continuity, reduced avoidable ED utilization, and strengthened overall performance under global risk.
Results (Within 12 months)
- ED utilization decreased to 300 per 1,000
- Avoided ~$4.8M in costs
- Member satisfaction improved due to increased support outside the hospital setting
Key Takeaway
Our approach embeds end-to-end care transitions, real-time visibility, and aligned resources as core strategies to reduce avoidable ED visits and improve performance under global risk. By strengthening coordination across the care continuum, organizations can achieve measurable gains in cost, quality, and patient experience.