Reducing Unnecessary Emergency Room Use: Best Practices 1

Reducing Unnecessary Emergency Room Use:

Best Practices1

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WSHA PresentersScott Bond Chief Executive Officer

Claudia Sanders Senior VP, Policy Development

Carol Wagner Senior VP,Patient Safety

Barbara GorhamPolicy Director, Access

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Partner PresentersWashington Chapter American

College of Emergency Physicians

Dr. Nathan Schlicher

Tim Layton Dr. Stephen Anderson

Washington State Medical Association

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Webcast Objectives• Overview• Emergency room overuse: a significant issue• History• The seven best practices• A fast timeline!• How we can help• Questions and comments

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An Opportunity

Redirecting Care to the Most Appropriate Setting

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Health Care is Changing

• Work with the state and partner physicians• To be sustainable in the long term:

– Adequate payment – Cost reduction

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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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Frequent UsersOne client:

All clients:

Focus on Patients Requiring Coordination (PRC)

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.005

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Enrollees per county

Is the ER the new medical home of the 21st century?

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Legislative Solutions

State Approaches to Curbing ER Use

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When What Impact Status Original proposal

3-visit limit on unnecessary use

Cuts payments to providers

Won lawsuit; policy abandoned

Revised proposal

No-payment for unnecessary visits

Cuts payment to providers

Delayed by the Governor just prior to implementation

Current policy

Adoption of best practices

Improves care delivery and reliance on ER as source of care

Passed in latest state budget

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Voices Heard

• Contact with legislators• Contact with media• Discussion of legal barriers

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Savings without Penalties

Provides the state with savings by asking hospitals, and their physician partners, to implement the right systems for care

If Unsuccessful

Revert to the no-payment policy.

$38 million in annual cuts!

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Ultimate Goal: Reduce Trend

Current projected trend

Changing the trend

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Partners Will Be There• Emergency room physicians will be pushing for

hospital adoption

The Seven Best Practices

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A) Electronic Health Information

Goal: Exchange patient information among Emergency Departments• Identify frequent users• Get access to treatment plans• Use in providing care• Exceptions for CAHs with

financial burden

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How to Accomplish

Emergency Department Information Exchange (EDIE)• 30 hospitals in Washington already using• EDIE can:

– Notify ED physician of frequency of ED visits and summary of ED discharges for past 12 months

– Share guidelines for patient with other hospitals– Load patient’s treatment plan, so ED physicians can view

• Costs:– Depends on number of ED visits– $2,000 to $5,000 setup plus $1,200 to $30,000 a year

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B) Patient Education

Goal: Help patients understand and use appropriate sources of care• Active distribution of

educational materials• WSHA/WSMA/ACEP brochure• Discharge instructions

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How to Accomplish

• Use WSHA brochures or customize for your hospital• Decide when and how to distribute

– Upon arrival, at discharge, or display prominently

• Incorporate into electronic discharge instructions, if warranted

• Train ED physicians on educating patients about the appropriate care setting– Presentation disseminated by ACEP

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C) Patients Requiring Coordination (PRC) Information

Goal: Ensure hospitals know when they are treating a PRC patient and treat accordingly• PRC clients = frequent ER users, often narcotic

seekers• Receive and use client list• Identify patients on arrival• Develop and coordinate case

management programs• Use care plans

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How to Accomplish

• Identify who at hospital receives and disseminates information on PRC clients

• Use information in EDIE to alert physicians– Frequent user = someone who has used ER five or

more times in the past 12 months• Make PRC care plans available to ER physicians• Best success with case management in ER

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D) PRC Client Care PlansGoal: Assist PRC clients with their care plans• Contact the primary care provider when PRC client

visits the ER• Efforts to make an appointment with the primary

care provider within 72 hours when appropriate• If no appointment required, notify primary care

provider that a visit occurred• Relay barriers to care to Health Care Authority

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How to Accomplish

• Develop system to call primary care providers during and after PRC visit to emergency room

• Develop system to relay issues regarding access to primary care to the HCA

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E) Narcotic Guidelines

Goal: Reduce drug-seeking and drug-dispensing to frequent ER users• Implement ACEP guidelines for prescribing and

monitoring of narcotics• Direct patients to better resources• Track data and follow-up with

providers who excessively prescribe

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How to Accomplish

• Change hospital policy to conform with ACEP guidelines: – Prohibit long-acting opioids and discourage injections– Screen patients for substance abuse– Refer patients suspected of Rx abuse to treatment– Other

• Train ER prescribers in narcotic guidelines• Consider joining “oxy-free” movement• When guidelines implemented, hospitals have

seen significant drop in visits

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F) Prescription Monitoring

Goal: Ensure coordination of prescription drug prescribing practices• Enroll providers in Prescription Monitoring Program:

electronic online database with data on patients prescribed controlled substances

• Target enrollment for ER providers : – 75% by June 15, 2012– 90% by December 31, 2012

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How to Accomplish

• WSMA and WA/ACEP encourage members to sign up

• Educate and encourage medical staff to enroll• Hospitals track enrollment of ER prescribers to

report to HCA by June 15 and December 31, 2012

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G) Use of Feedback Information

Goal: Review reports, ensure interventions are working• Report specified information to Health Care

Authority• Designate ER leader and quality manager to receive,

review, and act on utilization management reports• Involve executive-level leadership

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ED WORK GROUP

WSHA, WSMA, WA/ACEP and the state Health Care Authority will develop and monitor metrics on performance by hospital and by physician

– Example measures:• Rate of unnecessary visits• Rate of visits by PRC clients• Rate of PRC clients with treatment plans• Rate of prescriptions with long-acting opioids

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How to Accomplish

• EDIE produces standard reports• Hospitals may be called on to gather and

report other easily available data• Feedback reports will be made public

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Provider Training

• Hospitals must ensure providers are trained

• WA/ACEP will provide template:– Training providers on how to educate

patients on choosing the appropriate care setting– Training providers on guidelines for narcotic

prescribing and monitoring

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Quality Assurance

Each practice concludes:

“Hospital has a system of quality assurance and intervention and can routinely identify, report, and correct cases of provider noncompliance with these best practices.”

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Do Other Laws Still Apply?

•EMTALA •Medical malpractice•Prudent layperson preserved

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Quick Action Needed!

• Hospitals must submit attestations and best practice checklists to HCA by June 15, 2012

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If Unsuccessful in Signing Up

If hospitals representing at least 75% of Medicaid ER visits do not sign up, the state will revert to the no-payment policy.

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Best Practices Just First Step

• HCA will perform a preliminary fiscal analysis by January 15, 2013

• Focus:– Outlier hospitals with high rates of unnecessary

visits– High ER visits by PRC clients– Low rates of treatment plans for PRC clients– High rates of opiate prescriptions

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If Unsuccessful in Changing Trend

If the trend does not go down, the state could revert to the no-payment policy.

Projection

Actual trend

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Attestation Mailed to You

• Complete entire form

• Send to HCA• Send to WSHA• We will follow up!

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Ongoing Oversight: 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

Next Steps

How We Will Help

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Best Practices Are a Foundation

If we are serious about achieving this:

Hospitals and emergency physicians need to be looking for trends and patterns, intervene, make continuous change!

Projection

Actual trend

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For More Information

Carol Wagner, Senior VP, Patient Safety(206) 577-1831, carolw@wsha.org

Claudia Sanders, Senior VP, Policy Development(206) 216-2508, claudias@wsha.org

Barbara Gorham, Policy Director, Access(206) 216-2512, barbarag@wsha.org

For More Information

Pauline Proulxwww.washingtonacep.org

Tim Laytontim@wsma.org

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Questions and Comments

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