pediatric emergency department (ed) case management ramona waltman, rn, bsn, ccm childrens...

Pediatric Emergency Department (ED) Case ManagementRamona Waltman, RN, BSN, CCM

Children’s Healthcare of Atlanta


Why do patients use the ED?


Children’s Healthcare of AtlantaWho Are We?

• 3 Hospitals

•529 Beds

•24, 572 admissions for 136,769 bed days

•778,881 visits for 326,182 patients

•17 Neighborhood Locations

•5 Urgent Care Centers

•Marcus Autism Center

•1 Primary Care Office


Facts and Figures

• 200,000 yearly Emergency Department visits = 550 a day

• 100,843 Urgent Care Visits

• 46,551 Primary Care Physician Visits

• Serviced all Georgia counties, 43 states and countries around the world


Children’s Healthcare of Atlanta is the:

• One of largest Clinical Pediatric Provider in United States

• Largest Georgia Medicaid Provider

• 10th private employer in Georgia with 7800 staff

• Trauma Provider for pediatrics in Georgia

• Pediatric Rehabilitation Services

• Transplant Services

• AFLAC (Hematology/Oncology Services)

• Focus on Disease Management, Asthma and Diabetes


Transplantation Performed at Children’s Healthcare of Atlanta

• Liver, Kidney, Bone Marrow and Hearts

• 475 Kidneys

• 19 Livers, youngest and smallest patient weighing 2 pounds

• Only pediatric center in Georgia for heart transplants, performed 3 transplants in a 24 hour period, one of few centers for ABO incompatible blood types

• 62 Bone Marrow Transplants and cures for 30 patients with Sickle Cell Disease

• http://careforceconnection/Departments/TransplantServices/SitePages/Home.aspx


Strong 4 Life Program

• Addressing childhood obesity jointly through efforts and partnering with community support and government agencies in Georgia

• 40% of Georgia’s children are obese, making Georgia 2nd in the country for obesity in children

• Children’s Healthcare of Atlanta employees have lost 35,459 pounds with fitness opportunities


Why Children’s Healthcare of Atlanta is Crucial to Georgia

• 28% of Georgia’s total population are children

• 52% of those children are enrolled in Medicaid or Georgia’s State Children’s Health Insurance Program (SCHIP) known as Peach Care

• 300,000 of Georgia’s children are uninsured

• Children’s Healthcare of Atlanta provided $90 million in unreimbursed care in 2011


Where to go?


Georgia Medicaid

• Traditional Medicaid manages children who are eligible for supplemental security disability income and children in foster care

• The remainder of children enrolled in Georgia’s Medicaid program are enrolled in one of Medicaid’s care management organizations

– Wellcare

– Amerigroup

– Peachstate

• Another option is Peach Care, Georgia’s state child health insurance program. This option requires income eligibility and a monthly premium payment at a reduced rate for the families


• Convenience– Decreased wait times – Victims of our Own Success

• Perception of Quality of Care– ED access to diagnostic tests not available at Primary Care

Provider

• Transportation barrier among families– Often one car family (mother not driver) or a neighbor’s

car available

• Financial Incentive– Co-pays established for Primary Care Provider visits but

not Emergency Department visits by Care Management Organization for Medicaid patients

Why use the Emergency Department instead of Primary Care Providers?


Georgia Medicaid

• Traditional Medicaid manages catastrophic illnesses and children in foster care

• Remainder of Children are enrolled in Medicaid care management organizations– Wellcare

– Amerigroup

– Peachstate

• Nominal fee for coverage through Peach Care, which is Georgia’s state child health insurance program

“I am not feeling well, I vomiked twice!”When can I see you?


Patient Barriers to Primary Care Access

• Perceived barriers when contacting Primary Care Providers (PCP)

– Access to PCPs’ nurse advice line

• “If you feel you have an emergency hang up and call 911 or go to the nearest ED”

“ If you want to talk to a nurse or physician, this call will be subject to a $15 charge. Any calls to the CHOA nurse advice line will also be subject to a $15 charge. (Call center Services must charge fees due to Stark Laws while most insurance companies have a 24hr free nurse advice line) 1

• Limited availability “same day” and “after hours” appointments

– Compensation model from payers

1 Zaman Pediatrics After Hours Line 770-995-2946


Pediatric ED Case ManagerPosition and Scope of Work

• SR Case Manager position started Jan 1, 2012

• 1 FTE

• Staffed 8am-5pm 5 days/week (rotates between 2 main campuses)

• 2500 ED CM referrals in the first 6 months


Pediatrics ED Case ManagerKey Objectives

• Identify and reduce patient access barriers that result in non-emergent ED visits

• Target subset “high utilizers”

• Work directly with 3 Medicaid care management organizations (CMO) ED Case Managers to address payer specific barriers to primary care

• Support ED physicians to ensure adequate follow up for primary and specialty care

• Coordinate referrals to Patient Financial Services to determine financial eligibility for Medicaid

• Partner with ED physician and nursing staff to identify risk factors and patient specific conditions leading to 72hr ED returns

• Educate ED physicians on documentation of medically necessary admission criterias


• 3 Medicaid Care Management Organizations in Georgia– Daily list of ED visits sent to payers– Initiated communication with hospital and CMOs– Identify any actionable barriers to care that result in ED visits?

Identified contact individuals at each payer source Target frequent ED users (6 visits/rolling calendar year)– Identify actionable items representing barriers to access resulting in repeated

ED visits• Primary Care Physician assignment

– Assigned to a specialist instead of Primary Care Physician– Primary Care Physician assigned is great distance from home

• Transportation barriers among patients and caregivers• Lack of access to free or low cost medical and dental clinics for uninsured

pediatric patients• Provide community clinic lists

Connecting Patients and Payers


Case Manager Identifies Barriers to Outpatient Follow-Up

Neurology services– Reduction in physician providers on one campus from 7 to

4.5

– Neurology practices are non-providers in Medicaid and CMO plans for outpatient visits

Orthopedic services

– Resolved out of pocket expenditures for fracture patients covered by one CMO payer

– Identifying barriers to follow-up care for uninsured, Medicaid pending and non-documented citizens


• 2 new seizure clinics operationalized

– Decreased time for new seizure follow up appointments from 2 months to 1 week

– Clinic physicians provides Neurology Services for hospitalized patients

• Partnered with Neuroscience Service Line

– First Time Non Febrile Seizure Pathway

• CM responsible for ED patient follow-up

–Referral s of patient to Seizure Clinic

Outpatient Follow-Up BarriersFinding a Solution


Primary Care Collaboration

• Initiated meeting with Medical Director and staff of Primary Care

– Established communication to identify Primary Care patients with high Emergency Department utilization

– Reported scheduling issues identified at Primary Care

– Identified Primary Care patients who could benefit from Primary Care follow-up post Emergency Department visits

– Reporting initiated to provide data for Primary Care patients treated in ED setting, being shared weekly to identify need for follow-up at Primary Care


• Identified that uninsured patients (potentially eligible for assistance) receive limited follow up by our financial counseling team

– ED charges < $3,000/visit frequently routinely not recovered

• Problem identified by ED Case Manager

– Established a process to identify and refer patients to financial counseling

• Single ED visit > $3,000

• 6 emergency department visits in 12 month period

• Multiple siblings treated during same ED visit

• Out of state Medicaid patients who have moved to Georgia and need to transition/apply for Georgia Medicaid

– Currently tracking financial success with a goal of recouping 10% ED charges on patients eligible for coverage

Uninsured PatientsReducing the Financial Impact


• Are there trends of unscheduled ED return visits that can help identify high risk conditions and patients?

– Bronchiolitis

– Cellulitis

• Track unscheduled 72hr ED return visits categorized by

– Age of patient

– Payer source

– Diagnosis

– Reason for return to ED

Future Goals for Tracking


• Increasing pressure to justify medical necessity for short inpatient admissions

– Insurance denials

– RAC Audits

• Significant difference in compensation between Inpatient vs. Observation Admissions

• Educate physicians on documentation of medical necessity criteria for DRGs with 1-2 days LOS

– Asthma

– Pneumonia

– Bronchiolitis

– Acute Gastroenteritis

Admission Level of Care:Getting it Right on the Front End


Pediatric ED Case ManagerTracking Performance

• Patients with high utilization of ED services referred to each CMO

– Document follow up from payer at 3 months

– Assess impact in reducing non-emergent ED visits

• Number of uninsured patients referred to financial counseling

– Reimbursement received through retroactive Medicaid billing

• Medical predictors by DRG for 72 ED return and subsequent readmission

– Bronchiolitis (age, 02 saturation)

– Cellulitis (age, presence of abscess, location infection, presence of fever)


Meeting The Case Management Need

• Tracking patients who left without being seen

• Tracking patients who leave against medical advice

• Prevention of unnecessary ED visits

• Expanding the coverage to second campus


Summary of Patients Receiving Benefits of ED Case Management at Children’s Healthcare of Atlanta

• Patients needing specialty care follow up:

– Neurology

– Orthopedics

• Patients needing a better fit with their primary care physician

• Patients covered by Care Management Organizations (CMO) who need coordination of care

• Patients who are uninsured/non-documented and require continuation of care

• Patients covered by out of state Medicaid programs who reside in Georgia and need to transition to Georgia Medicaid

pediatric emergency department (ed) case management ramona waltman, rn, bsn, ccm childrens...

Documents

georgias children

peach care

primary care office

unreimbursed care

diabetes slide

world slide

urgent care visits

georgia counties