From the ACEP 2026 Scientific Assembly: The ED Can't Close the Continuity Gap Alone

In brief: ED leaders cannot solve frequent ED use inside the ED alone. The practical opportunity is narrower: identify the continuity questions that remain after stabilization, route them to the right primary-care or specialist partner, and document the next action. In Camden’s 800-patient randomized trial, a promising transition program did not reduce 180-day readmissions—why measurement matters before claiming impact.

Part of the “From the ACEP 2026 Scientific Assembly” FabrixMed Insights series.

Why does the ED keep seeing the same patients?

Many patients use the ED repeatedly because it is the most available part of the health system. The reasons are rarely simple. A chronic condition may be poorly controlled. A behavioral-health need may not have a reliable outpatient pathway. Medication access, housing instability, transportation, substance use, or the absence of a regular primary-care relationship may all shape what happens next.

The ED is built to handle the acute episode: assess, stabilize, treat, and determine the next appropriate disposition. That is essential work. It is not the same as longitudinal care.

The continuity problem begins when the next visit starts without the context of the last one. The emergency physician sees the immediate presentation. The primary-care team may not see the ED note. The specialist may not know that the patient’s condition has escalated. The community or behavioral-health team may be working from a different plan altogether.

This is not a failure of emergency medicine. It is a system problem created when responsibility and information are distributed across separate encounters.

For a related ACEP26 discussion of a different flow problem—ED boarding—see the companion article on capacity delay and specialty-access delay.

What did the Camden hotspotting trial actually show?

The Camden Coalition’s care-transition model became a widely discussed example of intensive support for patients with complex medical and social needs. The model used nurses, social workers, and community health workers to connect patients with outpatient care and social services after discharge.

The randomized trial enrolled 800 medically and socially complex hospitalized patients with at least one hospitalization in the preceding six months. At 180 days, readmission was 62.3% in the intervention group and 61.7% in usual care. The difference was not statistically significant. Read the study in the New England Journal of Medicine.

The memorable detail is the comparison that did not hold up. Looking only at the intervention group before and after enrollment made admissions appear to fall by 38 percentage points. The control group showed a similar decline. That before-and-after result was a regression-to-the-mean mirage, not evidence that the program caused the reduction.

The lesson is not that care coordination does not matter. It is that a plausible program should be evaluated against the outcome it is meant to change—and against a credible comparison. For ED leaders, that creates a more useful question: where does the continuity process actually break, and what part of that break can the ED influence?

Where does continuity break between ED visits?

The gap is often visible in the handoff:

• The ED team identifies a concern but has no reliable route to the patient’s primary-care or specialty team.
• The patient leaves with a recommendation, but no named team owns the next action.
• A specialist is contacted informally, but the question and recommendation are not documented where the next clinician can find them.
• The same diagnostic work is repeated because prior decisions or results are difficult to locate.
• A behavioral-health, addiction, or chronic-disease concern returns to the ED because the outpatient escalation path is unclear.

These are not all the same problem. Some require social services, housing support, behavioral-health resources, medication access, or changes in care management. A consultation workflow cannot solve those needs by itself.

But some failures are clinical coordination failures: the right question was not routed, the right specialist did not receive the relevant context, or the next action was never made explicit.

What would a continuity workflow look like?

The goal is not to turn every ED visit into a care-management program. It is to make the clinically relevant handoff more reliable when a defined question needs another team’s input:

1. The treating clinician identifies the unresolved question after the acute evaluation and includes the relevant history, results, images, medications, and concern.
2. The question is routed to the patient’s primary-care team, an approved specialist, or a configured coverage group with the organization’s response and escalation expectations.
3. The receiving clinician documents the recommendation, limits, escalation criteria, named owner, and next action so the responsible team can carry it forward.

The workflow should be designed around the organization’s actual participants and governance. It may use employed clinicians, contracted specialists, community partners, or a hybrid coverage model. It should not imply that a remote response replaces an in-person assessment, social-work intervention, or ongoing treatment relationship.

How can ConsultBridge help close the loop?

ConsultBridge supports provider-to-specialist consultation and care coordination. A qualified treating clinician can route a structured clinical question, diagnostic data, images, labs, and care context to the appropriate specialist for review, recommendation, and documented handoff.

For a high-need ED population, that may support workflows such as:

• a post-visit specialist question that needs an answer before the next appointment;
• an endocrinology or cardiology question related to recurring chronic-disease presentations;
• a behavioral-health escalation or disposition question within the organization’s approved clinical pathway;
• a transfer or treat-locally question when specialist input is part of the decision; or
• a follow-up handoff that makes the responsible team and next action visible.

ConsultBridge does not own the patient’s longitudinal care. It provides a structured way for qualified clinicians to ask, answer, document, and hand off a defined question when the organization has the appropriate coverage and governance in place.

CareScreen has a different role. It supports structured screening capture, clinical review, and practice-led follow-up for configured screening workflows. It should not be presented as a universal longitudinal record or as an automatic solution for frequent ED use. The two products may fit together in a broader operating model, but they solve different workflow problems.

What should an ED measure before claiming improvement?

The first step is to measure the continuity gap rather than label every repeat visit a failure. A pilot might track:

• the proportion of repeat ED patients with a documented primary-care or specialty handoff;
• time from a complete consult request to specialist review;
• time from specialist review to a named next action;
• completion of follow-up within the organization’s defined window;
• repeat testing or repeated diagnostic work where prior results were available;
• return visits associated with a pending specialty or follow-up question;
• escalation, transfer, admission, or discharge decisions associated with specialist input; and
• cases that require real-time or in-person evaluation rather than asynchronous review.

Readmissions and repeat ED visits are important outcomes, but they are not the only measures—and they should not be attributed to a consultation workflow without an appropriate evaluation design. Social conditions, disease severity, access, policy, and ordinary variation all affect utilization.

What does this approach not solve?

It does not build housing, treat addiction on its own, create a behavioral-health bed, replace primary care, or substitute for community-health workers and social services. It does not give one team ownership of every part of a patient’s life.

Its role is narrower: reduce avoidable clinical disconnection when a qualified treating clinician needs another clinician’s input and the organization has a defined pathway for routing, review, documentation, and follow-up.

The patients an ED sees repeatedly deserve more than another isolated encounter. The practical starting point is not a promise to eliminate repeat visits. It is to identify where the clinical loop breaks, make the missing handoff visible, and test whether a structured specialist-access workflow helps the next team begin with more context than the last one had.

Sources and further reading

• ACEP26 session planning page
• Finkelstein et al., Health Care Hotspotting—A Randomized, Controlled Trial
• FabrixMed ConsultBridge positioning
• FabrixMed CareScreen positioning

FabrixMed and ConsultBridge support clinical workflows; they do not replace emergency evaluation, primary care, bedside care, social services, specialist judgment, or local clinical governance.