Morehouse School of Medicine
We believe that there are many reasons that people with epilepsy get their health care through the emergency department (ED) instead of through primary care or neurology. Our goal is to create program that will address these reasons. The creation of this program will be informed by use of the Grady electronic health records (EHR). We will use the EHR to describe people with epilepsy coming the Grady ED at a high frequency. We create a profile of these patients by examining their demographics and social determinants of health information in their EHR (Aim 1). We will then use that information to create a culturally and medically appropriate program for people with epilepsy (Aim 2). Next, we will test the new program, the Epilepsy Emergency Department High Utilizer Program (Aim 3). We believe this program may improve three things. It will first improve access to care by epilepsy and mental health doctors, and reduce ED visits. It may also help people to manage their triggers, track seizures, and take their medicines on time. And last, we believe it may improve seizure frequency and quality of life for people that are underserved in health care. With the lessons learned from the new program, we will explore ways to sustain the program at Grady and expand it to other health care facilities (Aim 4).
Inclusion Criteria: * Adult women aged 18 years or older * Confirmed diagnosis of epilepsy documented in the electronic health record (EHR) * Enrolled in the Grady Health System Transition of Care (TOC) ED High Utilizer Program * History of three or more seizure-related emergency department visits within the past 12 months * Self-identify as Black or Hispanic * Reside in the Atlanta metropolitan area with intent to remain for at least 12 months * Have access to a working phone for follow-up communication Exclusion Criteria: * No confirmed epilepsy diagnosis (e.g., non-epileptic seizures) *…
Participants receive a community health worker (CHW)-led transition-of-care intervention for adults with epilepsy who frequently use emergency department services. Over 9-12 months, the CHW provides home visits and phone follow-up to support seizure self-management, medication adherence, and care coordination. The CHW assists with appointment scheduling, connects participants to healthcare and community resources, and addresses social needs such as transportation and access to care. The goal is to improve continuity of care and reduce emergency department utilization.
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