A new study led by Dr. Christopher S. Evans of East Carolina University examines the increasing number of patients who leave emergency departments (EDs) without being seen (LWBS) and their likelihood of returning for care within a week. The study, published in JAMA, analyzed data from the Epic Cosmos dataset, covering more than 1500 hospitals and 270 million patients across the U.S.

The research found that 18.5% of LWBS ED visits resulted in a return visit within seven days, with 1.63% requiring hospitalization and 0.19% needing intensive care unit (ICU) admission. Alarmingly, over 58% of these returning patients went back to the same ED, with a median time of 46.6 hours between visits. This pattern suggests that patients often return at the same time of day, possibly reflecting barriers to accessing alternative care options outside the ED setting.

Key patient characteristics associated with LWBS include younger age (mean 43.7 years), female sex (55.7%), and racial disparities, with Black patients making up 34.6% of LWBS cases. Additionally, 10.6% of LWBS patients had visited an ED in the previous 30 days, and those who returned within seven days were significantly more likely to have had a prior ED visit.

These findings have serious implications for healthcare systems struggling with ED overcrowding and prolonged wait times. The study underscores the need for alternative care pathways, particularly outside traditional business hours, to prevent avoidable return visits and hospital admissions. The limitations of the study include its reliance on data from Epic Cosmos hospitals, potentially missing return visits to non-participating facilities, and the lack of ambulatory care utilization analysis.

Overall, this study highlights the urgent need for systemic improvements in ED flow processes, enhanced triage strategies, and expanded access to urgent care services. Addressing these issues is critical to ensuring that patients receive timely and appropriate medical attention, rather than cycling back through overwhelmed emergency departments.

Leveraging Transitional and Chronic Care Management to Reduce Emergency Department Return Visits

To address the troubling pattern of patients leaving the emergency department (ED) without being seen (LWBS) and subsequently returning within days, healthcare systems must deploy proactive strategies that bridge the gap between emergency care and long-term health management. Two key interventions—Transitional Care Management (TCM) and Chronic Care Management (CCM)—offer structured approaches to improving patient outcomes while alleviating ED overcrowding and unnecessary hospitalizations.

The Role of Transitional Care Management (TCM)

TCM is designed to support patients transitioning from an acute care setting, such as an ED visit or hospital discharge, back into their community. Many patients who leave the ED without being seen do so due to long wait times, lack of immediate perceived urgency, or frustration with the system. However, these individuals may still require medical attention, and without structured follow-up, their conditions can deteriorate, leading to costly and preventable return visits.

By implementing TCM services, healthcare providers can intervene early by:

• Assigning a Care Coordinator: A dedicated professional reaches out within 24–48 hours of the initial ED visit, assessing ongoing symptoms and arranging follow-up care.
• Scheduling Timely Primary Care Appointments: Many LWBS patients struggle to access their primary care providers (PCPs) quickly. TCM ensures they are scheduled for in-office or telehealth visits, reducing reliance on the ED.
• Medication Reconciliation: A significant percentage of ED visits stem from poor medication adherence or adverse drug reactions. Reviewing prescriptions and ensuring proper usage can prevent deterioration and subsequent ED revisits.
• Patient Education and Self-Management Support: Equipping patients with knowledge about their condition, warning signs, and available outpatient resources empowers them to manage their health more effectively.

TCM is particularly critical for high-risk populations, such as older adults, patients with multiple chronic conditions, and those with socioeconomic barriers to healthcare access. A well-executed transitional care program can significantly reduce preventable ED revisits, hospital readmissions, and long-term healthcare costs.

The Importance of Chronic Care Management (CCM)

While TCM focuses on short-term follow-up after acute care episodes, CCM provides continuous, structured support for patients with chronic illnesses, helping them manage their conditions proactively rather than through emergency services. According to the Centers for Medicare & Medicaid Services (CMS), CCM is a vital tool in preventing unnecessary ED visits by ensuring regular engagement with healthcare providers.

Key components of effective CCM include:

• Comprehensive Care Planning–patients with chronic conditions such as diabetes, hypertension, heart disease, and COPD are at higher risk for ED visits if their conditions are not well-managed. CCM helps develop personalized care plans tailored to patient needs.
• Routine Check-ins and Monitoring–regular monthly contact with a care team helps detect warning signs of exacerbations early, preventing crises that might otherwise lead to an ED visit.
• 24/7 Access to a Care Team–many patients resort to the ED because they cannot reach their primary care provider after hours. CCM offers an alternative by providing continuous support through phone or telehealth services.
• Care Coordination Across Providers–many LWBS patients experience fragmented care, often seeing multiple specialists without clear communication between them. CCM facilitates coordination, ensuring that all aspects of a patient’s health are managed effectively.

TCM and CCM as Complementary Solutions & A Coordinated Approach

By integrating both TCM for immediate post-ED follow-up and CCM for ongoing chronic disease management, healthcare systems can create a continuum of care that reduces avoidable ED utilization. Patients who leave the ED without being seen often do so because of systemic barriers—lack of primary care access, social determinants of health, or unrecognized worsening conditions. By addressing these root causes, TCM and CCM provide long-term solutions that reduce patient reliance on emergency services, improve health outcomes, and enhance overall care efficiency.

Ultimately, investing in proactive, patient-centered care models is crucial for reducing ED congestion, minimizing repeat visits, and ensuring that patients receive the right care in the right setting at the right time.

CrossTx offers a cloud-based, professionally staffed turnkey TCM and CCM solution for clinics, health systems and health information exchanges to help reduce readmissions, improve patient engagement and quality scores as well as increase reimbursement.

Daniel O’Connor
Chief Business Officer