Too many trips: How Monarch is helping patients find better health, and steer clear of the emergency room

Nancy Boerner, MD, MBA, Chief Medical Officer

Monarch HealthCare and OptumCare Pacific West Region


Monarch HealthCare is an Independent Practice Association (IPA) and part of OptumCare®. Monarch delivers managed care coordination for over 200,000 patients in Southern California and participates in three accountable care organizations (ACOs). 

They provide country-wide coverage, contracting with 2,250 physicians in addition to employing 140 practitioners comprised of PCPs, advanced care providers, specialists and hospitalists.

Monarch HealthCare was facing the same issue as hospitals, payers, and patients across the country: too many non-emergencies in the emergency room (ER).

Medical problems that are less expensive and more convenient to treat in non-emergent care settings were, in large numbers, being brought to the ER. In 2015, this problem was put to newly hired Dr. Desmond Lew, medical director of Government Programs and head of the ER Steering Committee.

Dr. Lew formed a team consisting of nurse case management, social work, pharmacy, marketing, provider relations, quality management, health care economics and medical directors.

Diagnosing the problem

To date the team had made a consistent effort to educate patients about when to use the ER. They made sure patients were aware of nearby urgent care offices as an alternative. There was steady progress. Still, they knew there was room to improve.

A 2016 review of ER use done by Monarch health care economics business analysts showed an important data point: Medi-Cal patients (Monarch patients served by California’s Medicaid program) used the ER nearly four times more than commercial members. 

With 423 Monarch patients out of every 1,000 on Medi-Cal, this was a notable trend. Identifying the health problems leading to so many ER visits could make a substantial difference to both patients and the state-wide health care system.

The team dug further. They reviewed all patients with more than five ER visits per year, and found that the majority of the patients with frequent visits to the ER were Medi-Cal and Medi-Cal-Medicare (dual) patients. 

Three diagnoses were responsible for most of the visits: chronic pain, mental health condition and narcotic addiction.


Finding the opportunity

Monarch had a strong pharmacy and disease management department as well as a robust nurse case management team already in place. However, when it came to these diagnoses, the psycho-social dimension of care was key. 

Dr. Lew and the committee hit upon a winning strategy. Counting on their unique skills as counselors, Monarch HealthCare social workers would lead patient care coordination. Their expertise guided interventions aimed toward stabilizing health and improving wellness.

The social workers reached out to patients by phone and in-person. They expected a 20 percent engagement rate — and doubled it. Forty percent of all patients were successfully contacted. 

After trust was established the social workers evaluated patients, assessing for Monarch HealthCare programs that might benefit them. Patients were also connected with community resources providing housing, food, transportation and mental health, addiction and social services. 


Over the course of their contact, social workers reinforced the importance of regular care with their primary care provider as well as appropriate use of the ER and urgent care.

“Patients had a lot of worry around uncontrolled pain,” recalls social worker Alison Leff. “Helping to manage the anxiety related to pain management and health maintenance was very important.”

Additionally, some winning strategies for creating connection and building trust with vulnerable individuals began to take shape. Social worker Craig Pulido found that, “Visiting with patients face to face and bringing people tangible resources that improve their lives was essential.”

Reaping the reward

Early results of social work-centered patient outreach show promise. At 90 days after engagement, patients who had been in contact with the team reduced their ER visits by 10 percent compared with non-engaged patients. 

This translates to improved comfort for patients needing less care in the hospital setting.

Monarch HealthCare shows that a patient-centered intervention yielded better coordinated care and better health. Dr. Lew and his team are encouraged by the success of their work and look forward to furthering the mission of improving care and bettering health. 

The future holds more innovation. By being data-driven and relationship focused, Monarch HealthCare will continue finding ways to support wellness.


The views and opinions expressed herein are those of the authors and do not necessarily represent the views of OptumCare. The views and opinions expressed may change without notice. 

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