For more than 20 years, the Camden Coalition has sought to understand a persistent challenge in the U.S. healthcare system: why people with complex health and social needs continue to rely on the emergency department (ED). Today, this challenge is playing out against a backdrop of record-level hospital overcrowding that endangers patients, accelerates clinician burnout, and drives avoidable costs for payers. These pressures create strong incentives across sectors to find solutions, especially those that intervene before patients present to the ED. To test whether intensive care coordination could improve outcomes for high-need patients, the Camden Coalition conducted a randomized controlled trial (RCT) from 2014-2017, with hospital readmissions as the primary outcome. Across analyses of the trial, the intervention was associated with improved connection to benefits and to primary and secondary care in the community; however, ED use remained unchanged. This raised an important question: why were people with strong care coordination and established primary care still turning to the ED?

We decided to dig deeper into this issue by asking the people who know best: Camden Coalition patients. Between June 2024 and August 2025, we completed 110 surveys capturing ED visits by 50 individuals enrolled in Camden Coalition programs, with most surveys administered within days of the visit. The survey findings reveal how shrinking access to primary care leaves few real options for urgent concerns, creating an almost inevitable pathway to the ED, even for those doing everything “right.”

In fact, nearly two-thirds of ED visits were rated by patients as highly urgent, with 66% assigning their symptoms an urgency score of eight or higher out of 10. These were not mild or ambiguous symptoms that could easily wait for routine follow-up; they reflected situations where patients perceived an immediate need for medical evaluation. These experiences are unfolding within a broader national context of declining primary care access. A February 2025 study in JAMA Health Forum found that since the COVID-19 pandemic, access to primary care has declined sharply, with practices offering weekend hours dropping from 44% to 26%, and those providing advanced same-day scheduling falling from 60% to 26%.

Beyond declining access, often compounded by transportation barriers and housing instability, patients described encountering system constraints when they attempted to seek guidance for urgent concerns. Taken together, these findings point to a broader conclusion: ED overutilization reflects system design far more than patient behavior. As changes to ACA Marketplace subsidies and Medicaid eligibility take effect, they are likely to add further strain to emergency departments that are already stretched thin.

Real-time insights into ED use

Capturing experiences in the moment

To capture experiences as close to the moment of care as possible, community health workers and care team staff with backgrounds in nursing and social work administered structured, interview-style surveys to participants in two Camden Coalition programs, Housing First and Heartwise, who had an ED visit within the prior 14 days. These programs serve individuals with complex medical needs—including multiple chronic conditions and behavioral health comorbidities—alongside significant health-related social needs, and participants had ongoing engagement with a Camden Coalition care team. In total, the team completed 110 surveys documenting ED visits by 50 unique individuals across Camden and Gloucester counties in southern New Jersey, with several participants completing multiple surveys following repeated ED visits.

The Camden Coalition Health Information Exchange (HIE) played a key role by helping the team identify ED visits in real-time, enabling them to reach out to participants quickly. The timing of survey administration was critical: by capturing insights while experiences were still fresh, surveyors could gather detailed information about the barriers people faced in moments of acute need.

Timing of ED visits reveals gaps in primary care access

While about half of visits occurred during standard business hours, 52% took place outside typical office hours: 35% between 5 p.m. and midnight, and 17% overnight, when primary care options are especially limited. This distribution closely mirrors known gaps in primary care access.

Notably, even visits that occurred during business hours rarely involved attempts to access primary care first, suggesting barriers that go beyond office hours alone.  Patients described difficulty obtaining timely guidance, such as being unable to reach their primary care office, finding no appointments available, or encountering uncertainty about how to safely address urgent symptoms outside the ED. In these moments, the emergency department emerged as the most reliable option for urgent evaluation.

How system constraints redirect patients toward the ED

The surveys revealed an often unseen dynamic between patients and providers when urgent symptoms arise. Among surveyed visits, fewer than one in five patients sought any other form of care before going to the ED. For those who did attempt to contact primary care, many reported encountering clinical or logistical limits that narrowed their options for safe evaluation.

As Nurse Care Coordinator, Sandra Drake, RN recounted:

“One particular client said his doctor and his nurse from the program had educated him that [if he was experiencing] any critical symptoms—he mentioned shortness of breath, high blood pressure, or this immense headache because of the heart failure—like, go [to the ED].”

This pattern reflects genuine clinical constraints amplified by declining primary care capacity. Sandra also recounted a conversation with a physician colleague:

“And he says, ‘I don’t want somebody calling me with shortness of breath.’ They can’t even hear them on the phone, you know? And he was like, ‘But I don’t want somebody to call me with a blood pressure 200/160 and they have symptoms with it. I’m not going to adjust any medication; I’m just going to tell them directly to go [to the ED].’”

These examples highlight how, in the context of high-risk symptoms and limited real-time diagnostic capacity, primary care teams may have little choice but to rely on the ED for safe evaluation. The issue is not patient preference or lack of a medical home; it is how the primary care system with diminished accessibility and limited acute-care pathways manages urgent clinical uncertainty.

Recognizing the compounding effect of social and logistical barriers

Beyond clinical considerations, the surveys revealed how social and logistical barriers further constrained people’s options for care. Importantly, these constraints were not occurring in the absence of primary care. Most participants reported having an established primary care provider, yet for four out of five ED visits, patients did not seek care elsewhere before going to the emergency department.

Communication breakdowns were a major obstacle. Many participants described calling their primary care office and being unable to reach anyone, leaving urgent symptoms unresolved. Others reported being told no appointments were available or that offices were closed after hours. When combined with high symptom urgency, these access failures effectively eliminated alternatives to ED-based care.

Social barriers often compounded these challenges. Transportation difficulties, housing instability, and lack of reliable phone access made it harder for patients to follow up with primary care or use telehealth options. For some, the ED also served as a workaround for basic infrastructure gaps—offering transportation, temporary safety, or coordination that was unavailable elsewhere in the system.

As Ya’Shauna Jones, the survey project manager, emphasized:

“[Patients] are already struggling with so much to get the care they need. They have to navigate transportation, getting their medications after discharge, or even having a place to properly store them; some are unable to follow up with their PCPs or reach out to telehealth services because they don’t have access to a phone.”

In many cases, patients described arriving at the ED after encountering multiple, overlapping system-level constraints that left few viable alternatives. Behavioral health needs further intensified this dynamic: anxiety, panic attacks, and crisis situations often left patients with limited options outside of emergency care.

Taken together, these findings underscore that ED use is shaped by a web of clinical, social, and system-level constraints. When access breaks down across multiple fronts at once, the emergency department becomes not a preference, but the most reliable, and sometimes only, pathway to care.

Rethinking acute care access

Even when people are connected to primary care, understand their conditions, and want to seek care in the “right” place, the structure of the healthcare system often leaves them with few viable options. Declining primary care capacity, limited acute-care pathways outside the ED, and persistent social barriers create a situation in which emergency departments become not the last resort, but the only accessible one. These realities point to several critical implications for policymakers, health systems, and care teams working to reduce avoidable ED use.

This helps explain another striking finding: 81% of respondents reported being satisfied with the care they received in the ED, underscoring why emergency departments remain a dependable—and often the only—place people feel they can turn in moments of crisis.

Improving connections to primary care is only part of the solution. While the Camden Coalition’s RCT confirmed that care management can reliably link people to providers, the survey shows that acute care patterns don’t shift simply because primary care relationships exist. Primary care teams often lack the capacity, time, or tools to safely evaluate urgent symptoms in real time without relying on the ED.

This is happening against a backdrop of shrinking primary care capacity and within a broader emergency care environment already strained by crowding and boarding, where people who need to be admitted to the hospital end up waiting for hours or even days in emergency department beds. Fewer weekend hours, fewer same-day appointments, and tighter schedules mean that EDs have become the pressure-release valve for a system stretched thin.

Taken together, these results are a reminder that high ED use is not a patient choice problem; it’s a system design problem. People are doing what they’ve been instructed to do, or what the system has effectively made necessary, using the only door that reliably opens when they need help. Until we improve real-time access to primary care, expand behavioral health supports, and give providers the tools to safely assess acute symptoms outside the ED, the pattern won’t change.

At the Camden Coalition, these findings have shaped how we approach this work. Longstanding patterns of high emergency department use led us to deepen cross-system efforts for patients who repeatedly cycle through the ED, including complex case conferencing among providers serving the same individuals. Those same patterns also motivated the earlier development of our Ecosystem Alignment Tool, a structured approach designed to help healthcare and community partners step back and identify where system-level practices, such as communication, workflows, data sharing, and decision-making, need to be strengthened to support alternatives to ED-based care. Together, these approaches reflect a shift from focusing solely on individual interventions to addressing the broader ecosystem conditions that determine whether those interventions can succeed.