Presented By:

ED Trends in Sacramento County Managed Medi-Cal Meeting

Monday, July 28, 2014

Holly Harper, Community Benefit Manager, Sutter Health Sacramento Sierra Region Rosemary Younts, Director, Community Benefit, Dignity Health

Ellen Brown, Community Benefit Manager, Kaiser Permanente South Sacramento Laura Niznik, Manager, Government & Community Relations, UC Davis Health System

Shared Concerns • Inefficient use of healthcare dollars • Using Emergency Departments for primary care is:

– Bad patient care – Expensive and Inefficient; and – “Clogs” up our systems for people with true emergencies

• Inability to schedule timely follow-up appointments with providers

• High clinic sliding scale fees for patients not eligible for coverage

• Lack of enough outreach, adequate collaboration, education and care coordination

• Lack of primary/mental healthcare capacity for target population

Sutter Medical Center, Sacramento: Emergency Department Primary Care/Non-Urgent Data • In 2013, more than 15% of all ED visits were “Level 1&2s” or NON-

URGENT. 77% of these visits were for our ‘underinsured populations’, including: – 15%: Uninsured – 11%: County insured – 51%: Medi-Cal

• About 70 percent of non-urgent visits fall between 8 am – 8 pm (More visits between Friday-Tuesday)

• 2014 is trending more of the same and we are seeing the following trends in non-urgent ED usage – 12% increase in Medi-Cal patients seeking primary care in the ED. – 10% decrease in uninsured

1,091

6,695 1,435

1,254

1,991

122 236 95 247

MedicareMedi-CalCountyCommercialSelf PayCAP-Commercial RiskOther General InsCAP Medicare RiskSutter Select

Emergency Department Non-Urgent Visits by Plan - 2013

ED Navigator, Sacramento • WHAT: WellSpace Health houses Emergency Department Navigators who approach all

ED users to assess and address health access needs, including: ensuring access to services at community health settings; directing and providing functional support for benefits acquisition; engaging hard-to-meet GMC providers; assistance with securing benefits, housing, and other ancillary supports.

• WHERE: Sutter General Hospital Emergency Department • WHEN: 12:00 pm - 8:30 pm, 7 days a week. • THIS QUARTER: SMCS Navigators connected with 117 patients, providing all of them

with referrals and services, while enrolling 47 of them in T3 to receive case management services.

Last year alone, SMCS Navigators provided more than 1,577 referrals to insurance, medical, income, housing and other services. For an average of 6.24 referrals per patient.

• Program Objectives of T3: The T3 program serves homeless, low income, and/or

dually diagnosed individuals within Placer County by: –Bridging clients to a primary care provider, psychiatric care and counseling as needed –Reducing non-emergent ED visits –Obtaining insurance entitlements –Obtaining financial entitlements –Providing intensive wrap-around case management services

• Since inception, T3 has served nearly 1,000 clients, with 190 current active clients. – In the last quarter, 34 patients were enrolled, with 1881 referrals provided in the

same time period – Patient level data shows non-urgent ED visits decreased by 85% following T3

intervention. – Of the patients that did return to the hospital following T3 intervention, we see

they are healthier overall, with fewer instances of chronic conditions and major health issues

Emergency Department Primary Care Data • Today, over 50% of all Emergency Department visits are for primary care

– Versus 20% in 2009 – Consistent across all 4 Dignity Health hospitals

• Mercy General, Mercy San Juan Medical Center, Methodist, Mercy Hospital of Folsom

• Primary care identified using discharge diagnoses • Almost 60% of these visits for primary care are by uninsured and Medi-Cal-

insured patients – Represents over 50,000 unique patients with multiple admissions

• 50% of these visits for primary care occur during business hours • In first six months of ACA, beginning to see shift in patient type admitting

for primary care – 6% increase in GMC patients – 3% increase in Medi-Cal FFS and/or SOC which could account for those still

pending in Medi-Cal system – 3% decrease in uninsured

Emergency Department Primary Care Visits by Plan

Anthem Blue Cross GMC

Health Net GMC

Molina GMC

Other GMC Medi-Cal

FFS and SOC Medi-Cal

Uninsured

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

FY12 FY13 FY14

18,030 18,496 15,143

10,071 8,502 9,834

324 563 547

5,365 6,294 6,995

9,273 11,619 13,067

15,258 16,434 17,284

58,321 62,870 61,908

Emergency Department Patient Navigator Program • Partnership with Sacramento Covered and Health Net • Ensures patients can access timely, appropriate primary care, decreases

dependence on emergency departments and reduces cost • 6 on-site Sacramento Covered navigators provide direct assistance to Medi-

Cal-insured and uninsured patients admitting to emergency departments for primary care

√ Determine patient’s assigned Medi-Cal providers √ Make timely follow-up appointments with providers √ Help uninsured get established at a community clinic √ Connect patients to additional community resources √ Educate patients on current health plan coverage √ Enroll patients in Dignity Health’s chronic disease programs √ Conduct reminder calls prior to scheduled appointments √ Arrange transportation on case by case basis √ Follow-up with patients after appointments

• Incorporates IT using MS4, Cerner, MobileMD and Health Net Provider Portal

Patient Type Served Since Program Start Up in Mid-August

Insurance # of Patients % of Total Appointments Scheduled

Health Net GMCP 512 13.8% 360 Blue Cross GMCP 303 8.2% 219 CMISP 11 0.3% 3 Emergency Medi-Cal 110 3.0% 101 FFS Medi-Cal 610 16.5% 526 Medi-Cal Share of Cost 24 0.6% 19 Molina GMCP 144 3.9% 113 Molina LIHP 50 1.3% 39 Other 95 2.5% 51 Pending Financial Assistance 1353 36.5% 1104 Uninsured 493 13.3% 420 Total 3705 100.0% 2955

Participation by Clinic

• Account for 75% of all visits scheduled by navigators

Clinic/Provider # of Appointments Elica Health Center clinics 1255 Wellspace Health clinics 497 HALO clinics 317 Molina Healthcare clinics 98 Primary Care Clinic Stockton 30 Sacramento Family Medical Clinic Rancho Cordova 25

Program Outcomes • 3,705 patients assisted mid-August 2013 through June 2014 • 2,955 or 80% of patients served scheduled for follow up visit with assigned

provider or clinic • With program operating nearly a year, now able to begin measuring patient

outcomes by evaluating admissions/readmissions 6 months pre and post navigator assistance

• Initial evaluations show a significant reduction in readmissions by patients assisted - as much as 68%

• Finding that the program is also reducing urgent care visits – Assumption is that connection/reconnection to provider or clinic is preventing medical

conditions from becoming urgent

Program Outcomes – All Patients Served First Quarter

<-- based on unique patients

<-- based on total visits

Primary Care Visits Urgent Visits

Insurance

Patients Served First Quarter

FY14 6 Months Prior to

Assistance 6 Months Post

Assistance 6 Months Prior to

Assistance 6 Months Post

Assistance

Unique Patients

Total Visits

Unique Patients

Total Visits

Unique Patients

Total Visits

Unique Patients

Total Visits

Blue Cross GMCP 65 43 109 25 58 38 104 13 38 CMISP 2 1 1 0 0 1 1 0 0 Emergency Medi-Cal 4 3 4 1 2 1 2 0 0 Health Net GMCP 76 61 120 29 68 30 70 15 34 Medi-Cal 65 47 72 18 58 35 60 16 33 Medi-Cal Share of Cost 3 2 3 2 2 1 1 0 0 Molina GMCP 31 21 42 12 24 23 37 12 19 Molina LIHP 15 10 29 10 25 13 26 6 13 Other 13 9 20 4 14 7 10 5 11 Pending Financial Assistance 213 132 194 44 86 111 149 52 92 Uninsured 104 58 74 20 36 55 69 19 29 Total 591 387 668 165 373 315 529 138 269

% Admissions (Unique Patients/Total Served)

65% 28% 53% 23%

37% Fewer Patients Admitted 30% Fewer Patients Admitted

% Change in Total Visits Decrease of 295 Patient Visits After Assistance (44% Decrease)

Decrease of 260 Patient Visits After Assistance (49% Decrease)

Program Outcomes - Health Net Patients Served Second Quarter

<-- based on unique patients

<-- based on total visits

• Evaluation allows for enhanced focus on frequent users

Primary Care Visits Urgent Care Visits

Hospitals

Patients Served Second Quarter FY 14

6 Months Prior to Assistance

6 Months Post Assistance

6 Months Prior to Assistance

6 Months Post Assistance

Unique Patients

Total Visits

Unique Patients

Total Visits

Unique Patients

Total Visits

Unique Patients

Total Visits

Mercy Folsom 8 8 17 2 4 3 11 4 9 Mercy San Juan Medical Center 29 26 39 8 13 7 13 5 11 Mercy General 23 16 34 9 22 10 22 9 14 Methodist 70 59 88 11 18 20 29 12 18 Total 130 109 178 30 57 40 75 30 52

% Admissions (Unique Patients/Total

Served)

84% 23% 31% 23%

61% Fewer Patients Admitted 8% Fewer Patients Admitted

% Change in Total Visits Decrease of 121 Patients Visits After Assistance (68% Decrease)

Decrease of 23 Patient Visits After

Assistance (31% Decrease)

• Of total Emergency Department visits to three area Kaiser Permanente (Sacramento, South Sacramento and Roseville) medical centers: – 68% (197,290) are by members, 32% (91,190) are by non-

members • Of total ED primary care visits by Medi-Cal enrollees (Sacramento

GMC and FFS): – 39% (19,900) are by members, 61% (31,670) are by non-

members • Primary care visits by Medi-Cal enrollees increased 53% between

May 2013 – May 2014 – During same time period, total ED visits increased 11%

02000400060008000

1000012000140001600018000

May 2013-May 2014

3,647

2,799

1,588 1,971

6,683 KAISER PERMANENTEMEDI-CAL EDSMOLINA HEALTHCAREHEALTH NET MEDI-CALANTHEM MEDI-CAL

Emergency Department Primary Care Visits by Plan

- South Sacramento ED -

• ED use is part of larger discussion regarding Medi-Cal membership growth

• Historically, EDs have not focused on Level 1&2 visits unless member/patient has high utilization of the ED

• Reviewing education mailer to members showing examples of routine/non-urgent/urgent/emergency care and what do

• Considering navigator program for non-members • Non-members may be candidate for T3 (Triage, Treatment &

Transport) program with WellSpace Health – T3 Foothills and South Sacramento T3 serve frequent users of

the ED who also have mental health needs and engage them in appropriate primary and preventive care as alternative to ED

Emergency Department (ED) Primary Care Data • Approximately 25% of all outpatient Emergency Department

(ED) visits are for Primary Care Relatively unchanged first 4 months of 2014 vs. the last 6 months of 2013

• More than 50% of these visits for Primary Care occur during business hours

• Increase in number of GMC patients - 33% to 40% 7% increase

• Decrease in number of Self Pay & Pending financial aid - 21% to 15% 6% decrease

• Emergency Department (ED) Physician Triage Program Initiated to reduce length of stay in ED

Places physician in ED to see patients more quickly

Ability to expedite labs and radiology orders

Currently 10 am – 6 pm; looking to do 24/7

• Revising discharge process • Reducing wait time to open beds in ED

• Better education for discharged patients with home care instructions

• Looking at other methods to reduce primary care visits to ED

Questions?