Process Improvement in ACOs: Evaluating the Impact of Post-ED Outreach on Utilization Patterns

Michigan Medicine implemented a post-Emergency Department (ED) call program to support Accountable Care Organization (ACO) patients during a vulnerable care transition and address utilization goals in a risk-based contract. A clinical team member contacts patients the day after an ED discharge to check on symptoms, review discharge instructions, confirm access to medications, and coordinate follow-up with the primary care team. When appropriate, patients also receive education on navigating care options and appropriate ED use. Early results show a meaningful reduction in repeat ED visits, particularly among female patients. Just as importantly, patients report feeling reassured by the outreach, often sharing that they face barriers to reconnecting with their primary care provider and value having a timely, personal touchpoint after discharge. This session will highlight outcomes, patient perspectives, and practical strategies for implementing scalable post-ED outreach programs in accountable care settings.

Identify the impact of structured post-ED outreach on repeat ED utilization and patient confidence during care transitions.

Recognize key factors that contribute to effective post-discharge follow-up, including timely contact, patient education, and coordination of primary care.

Apply lessons from the Michigan Medicine program to design scalable, patient-centered interventions that improve outcomes and align with value-based care priorities.