here are numerous reports that link the economic downturn to increased use of emergency departments (EDs). For example, in The Washington Post, Larry Gage, president of the National Association of Public Hospitals and Health Systems, stated that "the absolute number of people using emergency rooms has gone up as much as 20% to 30% in the last six to eight months due to the recession." 1 The same article reported that Providence Hospital in Washington, DC experienced a 13% increase in emergency

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... oom visits in the previous year. Carolinas HealthCare System, centered in Charlotte, North Carolina provides the majority of safety net care for the Charlotte-Mecklenburg region; yet interestingly enough, the EDs at our hospitals are not experiencing similar trends as the rest of the nation. Comparing the first five months of 2009 to the first five months of 2008 shows only a slight increase in ED visits (0.5%) for all of the Carolinas HealthCare System's Mecklenburg County hospitals. This is during a period in which our region is experiencing overall population growth, rising unemployment rates, and increasing numbers of people without health insurance. This commentary will explain some of the strategies implemented at Carolinas Medical Center over the past decade that are helping to control ED utilization. Carolinas HealthCare System (CHS) is a large, vertically integrated health care system with facilities in North and South Carolina. The flagship hospital, Carolinas Medical Center (CMC), is an 808 bed facility and a Level I Trauma Center. As in many cities, our safety net hospital serves a significant role in providing access to services for underserved populations. CMC also serves as one of North Carolina's five academic medical center teaching hospitals, providing residency training for over 200 physicians in 15 medical specialties. Additionally, CMC operates primary care clinics for uninsured and underinsured patients in four strategically located areas of the city. These clinics, along with affiliated specialty care clinics, provide medical care to over 70,000 low-income individuals in 250,000 annual visits.