reducing preventable emergency room visits june 15, 2012 1
TRANSCRIPT
Reducing Preventable Emergency Room Visits
June 15, 2012
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WSHA Presenters
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Carol Wagner Senior VP,Patient Safety
Amber TheelDirector,Patient Safety
Presenters
Harborview Medical Center
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Brigitte Folz, ACSW, LICSW,Interim DirectorPsychiatry and Behavioral Health
Harborview Medical Center
Ann Allen, Lead High Utilizer Case Manger
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An Opportunity: Patients, when possible, should be treated by their primary care provider for non-emergency conditions in order to promote consistent, quality care helping protect physician/hospital payments.
• By June 15, 2012 hospitals must have implemented best practices on:– Electronic health information– Patient education – High-user client information/identification– High-user client care plans– Narcotics prescriptions– Prescription monitoring– Use of feedback information
• By January 1, 2013 hospitals must demonstrate reduction in low acuity visits• If unsuccessful, physicians and hospitals will suffer major cuts in Medicaid ER
payments
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Partnering for Change
• Washington State Hospital Association • Washington State Medical Association• Washington Chapter of the American College
of Emergency Physicians
Emergency Room Overuse: It Is a Problem
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Medicaid ER Use Is High
In the past year: • About 40% of Medicaid clients visited an ER• About 18% of people with private insurance
visited an ERContributing factors:
Lack of primary care Substance abuse Mental health
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Mental Health
• In the last decade emergency departments have seen a dramatic rise in the presentations for mental health related issues.
• In 2007, 3.2% of presentations to emergency departments were mental health related, this is over 190,000 presentations.
• Mental health issues are often complicated by substance abuse
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Barriers
• Poor historian• High anxiety• Lack of resources (housing, medication etc.)• High incidence of substance abuse
UW MEDICINE PATIENTS ARE FIRST
WSHA WEBCAST – JUNE 2012
HIGH UTILIZER CASE MANAGEMENT PROGRAM
HIGH UTILIZER CASE MANAGEMENT TEAM
• Since 2009 this HMC, Regional Support Network, and MIDD-funded program has provided prevention, intervention, and linkage for Emergency Department high utilizers
• The case managers provide assertive outreach and engagement for a designated high utilizer caseload.
• Individuals receive intensive services, including intensive outreach and advocacy to provide linkage for housing, chemical dependency, mental health, and medical follow-up.
• Current HUP Case Management team consists of: 1 Mental Health Practitioner Lead 2 Mental Health Practitioners 1 Program Assistant: staff support shared with another contract
funded project.
• Reached full capacity in August of 2009.
CM PRINCIPLES AND INTERVENTIONS
• Program is based on successful UCSF ED Case Management Program
• Assertive efforts to engage patient in ED and in the community
• Respectful and compassionate care
• Relationship building in the field Shelters, parks, freeway
ramps, agency waiting rooms, fast food restaurants, buses
• Concrete resource provision – food vouchers, bus tickets, etc.
• Harm reduction approach to CD issues
• Motivational strategies
• Networking with agencies to provide continuity of care
• Close team communication and supports
• Client self determination and care planning
• Network care conferences
MEASURING IMPACTS• Up to 30 active patients on the program
caseload at any given time
• Expected LOS is 3 months
• HMC Decision Support identifies and provides ED high utilizer data
• Number of ED visits and cost associated are collected
• Early data showed a decrease in jail admissions
• First year results showed a 67% reduction in ED visits
• Newer data shows a 50% reduction and also significant inpatient admission reduction
CASE PROFILE• High utilizer criteria: 4 ED visits in a six-month
period
• Homeless or in danger of losing housing
• Lack of effective engagement or alienation from traditional resources
• Increasing inability to cope with street life due to medical concerns
• Most clients have concurrent mental health, chemical dependency, and medical concerns
• Most common linkage needs: funding, primary care, chemical dependency treatment, mental health treatment, and housing
• Housing need is a huge barrier to long term stability
CASE STUDY #1• ~50 y. o. man
• Homeless
• Chemical dependency – primarily alcohol
• Increasing medical problems with multiple ED visits for cellulitis and withdrawal seizures
• Legal issues
• Interventions: Assertive outreach and
engagement Supported housing Bus tickets Aggressive networking
of supports• Key network linkages:
Reach Seattle Indian Health
Board DSHS - NA outreach
worker Chemical Dependency
Involuntary Treatment Services
Supported housing KC Detox
• Now sober, stable housing, reconnected to family and native community
CASE STUDY #2• ~40 year old man
• Multiple medical problems including diabetes and chronic back pain with non-compliance with medications and physical therapies Alcohol dependent Depressed In danger of losing his housing
• Enrolled in mental health but not engaged; case manager engaged in medical advocacy.
• Intervention Care plan developed to include time management,
motivational interviewing, and communication skills as well as focus on behavioral positive reinforcement.
• Now patient is increasingly engaged with his mental health providers, returned to physical therapy, actively managing his diabetes. Working on his CD issues (not yet clean). He was able to retain his housing.
SPECIALIZED CLINICAL INTERVENTIONS
• Care plans
• Case review – network planning
• Outreach and engagement in the community
• Crisis case-management
• Social services focused interventions
• Harm Reduction
• Advocacy stance
CASE REVIEW PROCESS
• Community Collaboration to engage and plan for • patient services• County Organized Coalition: High Utilizer Group• Data sharing• Assigning roles• Community Ownership of the Care plan
• Outcomes suggest that after collaboration use decreases for 60% of individuals
ED PATIENT CARE PLAN EXAMPLE
1) Issue: ______________with a history of high utilization of multiple EDs, health care systems. Pt has a hx of calling 911 seeking assistance which frequently turns out to be anxiety related…………
2) Key Health Concerns:…….Most frequent urgent complaints include:…….Other Health Concerns:………… 3) Professionals Involved in Patient’s Care : Pt currently has a stable Primary Care Physician for the past 24 years is ______________Pt’s primary hospital is ______________…………. Pt is currently on a Review and Restriction Program from DSHS. Ann Allen, HMC High Utilizer case manager (206) 744-5838.
4) Action Needed/Suggested: The emergency department can provide screening evaluation to determine her need for treatment any emergent medical condition. She responds best to one on one reassurance and choices rather than limits…………………… For example………..This care plan was created in consultation with her primary care physician_______
LIFE IS COMPLICATED
Mental Health
Housing
Medical Care
Funding
Chemical Dependency
Criminal Justice
ED VISIT DATA PER PATIENT: YEAR 1
0
5
10
15
20
25
30
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34 Individuals in Case Mgmt Program
ED Visits by Individual Pre and Post Case Management
Pre CM ED Visits Post CM ED Visits
Many patients had no ED visits
after case management.
PRE- AND POST-SERVICES COMPARISON: ED
CHARGES
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1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000 pre-case total charge; 5,322,592
pre-case charge_ED; 1,612,429
post-case total charge; $2,337,969
post-case charge_ED; $833,168
Total Charges and ED Charges(Most recent data)
pre-case total charge pre-case charge_ED post-case total charge post-case charge_ED
2012 RESULTS
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
1.80
2.00
Average ED Visits Per Client Per Month
Pre-Case, 1.25
Post-Case 0.68
REDUCTION IN ED AND INPATIENT VISITS
Pre_case Post-case0
100
200
300
400
500
600
700
INP; 140
INP; 56
OUT; 632
OUT; 329
Pre & Post CM: Patient Visit by Type
IN CONCLUSION
• High risk of morality in cohort (substance abuse and chronic illnesses)
• Opiate and benzodiazepine dependence
• Community mental health services found to be a willing partner
• Chronic substance abuse and long term care challenges
• Information sharing via High Utilizer ROI
• Housing, housing, housing• .
PROGRAM CONTACTS
Brigitte Folz, LICSW(206) [email protected]
Ann M. Allen, LICSW(206) [email protected]
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What are the three top priority strategies that hospitals could use to make the biggest impact now?
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Quick Action Needed!
Hospitals must submit
attestations and best practice
checklists to HCA by June 15, 2012
Looking for the last handful of hospitals to send their attestations in.
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Best Practices Just First Step
• HCA will perform a preliminary fiscal analysis and report to the legislature by January 2013
• Hospitals need to demonstrate a reduction in emergency room visits
If Unsuccessful
Revert to the no-payment policy.
$38 million in annual cuts!
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Ongoing Oversight and Measurement: Emergency Department
Workgroup• Health Care Authority• Washington State Chapter of the
American College of Emergency Physicians (WA/ACEP)
• Washington State Medical Association• Washington State Hospital Association
Questions and Comments
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