Webinar: Right-Sizing Your ED Amid Health Reform

RIGHT-SIZING THE EMERGENCY DEPARTMENT IN HEALTH CARE REFORMMODERN HEALTHCARE WEBINAR – OCTOBER 8, 2014

Randy Pilgrim, MD, FACEPEnterprise Chief Medical Officer

Jesse M. Pines, MD, MBA, MSCEDirector of the Office for Clinical Practice Innovation Professor of Emergency Medicine and Health Policy

Brent R. Asplin, MD, MPHChief Clinical Officer

PRESENTERS

RIGHT – SIZINGTHE EMERGENCY DEPARTMENTIN HEALTH CARE REFORM

Emergency Departments must continue to deliver excellent care for acute illness and injury.

Traditional functions must be refined and enhanced.

Changing the traditional approach to intermediate and complex conditions results in significant near-term value.

The Emergency Department will redefine key functions:▪ Patient care coordination▪ Best use of the health care system

Building early organizational capacity and capability is key.▪ Get ahead of the curve▪ Build a plan▪ Start now

EMERGENCY MEDICINE IN HEALTH REFORM

Fundamental drivers of change that impact the ED

Tactics for short term effectiveness and long term readiness

Functions in the ED that should be augmented, newly created, or curtailed

Preparing for new reimbursement models

Frameworks for assessing the readiness of your ED for change

IN THIS WEBINAR, WE ADDRESS:

HEALTH CARE ANDTHE EMERGENCY DEPARTMENT:BACKGROUND AND PERSPECTIVES6

ED treats a broad range of medical and surgical conditions▪ 130 million annual ED visits in the U.S.▪ Emergent care: 10-16% of visits▪ Intermediate/complex conditions: 31-57% of visits▪ Minor conditions: 12-40% of visits

Emergency care represents 7-11% of health care costs

EMERGENCY MEDICINE: FACTS & REALITIES

The ED as the hub of the enterprise:▪ Patient experience and community perception▪ Quality measures▪ Market share and revenue▪ Medical staff satisfaction▪ Utilization and cost

EMERGENCY MEDICINE: FACTS & REALITIES

Existing demand for ED care

Broad range of patients

High fixed cost

Center for decision-making ▪ Hospitalization▪ Advanced imaging▪ Coordination of care

Centralized management hub▪ Prioritization and implementation of initiatives▪ Flexibility for rapid-cycle adjustments

24/7 availability9

WHY LEVERAGE THE ED?

“RIGHT-SIZING” THE ED INVOLVES:

1. The ED itself Foundations and fundamentals Expand care coordination

2. Right-sizing key interfaces Admissions Near-admissions

3. Right-sizing patient care after the ED encounter Transitions of care Patient care follow up

4. Right-sizing utilization of the ED Best use of the health care system

Foundations• Acute treatment of sick & injured• Treatment of time-sensitive conditions• Rapid diagnostic center• EMS direction and coordination• Disaster preparedness & response• Safety-net care

Recent Changes• Two-midnight rule compliance• Readmission prevention• Quality measure compliance• HCAHPS (and ED-CAHPS) performance• Certification & regulatory standards• Documentation for hospital-acquired conditions • Care transition management

After the ED Visit(For post-ED patients with high-cost conditions)• Telemonitoring• Primary care integration• Patient engagement strategies• After-care visits• Care management• Assistance with palliative care• Disease management• Medication monitoring

Before the ED Visit• Assist employees/employers with

optimal site of care for certain illnesses or injuries

• Assist patients with access to office-based care

• Coordinate care with health plans• Manage care-seeking behavior• Direct patients to best site of care

KEY DRIVERS OF CHANGE Value-based purchasing Novel payment mechanisms Cost management imperatives Fragmentation of care Insufficient access to primary care Emergency department crowding Overall reductions in revenue per

patient

e “F

ED-Focused Outcomes

The Emergency Department as a Value-Driven Asset

Key Hospital Outcomes

Value-Driven Health System

Coordination & Continuity

Evolving Care• Treatment of intermediate conditions• Treatment of complex chronic conditions

What is the most important way that EDs need to change to improve value in health care?

A. Increase in size to accommodate higher demand and reduce crowding

B. Expand services to enhance care coordination with non-ED physicians

C. Decrease in size so patients can go to more appropriate settings

D. Work on internal processes to improve treatment pathways

POLL QUESTION

RIGHT-SIZING THE ROLE OF THE EMERGENCY DEPARTMENT

The ED must have excellent foundations Acute illness and injury Time-sensitive conditions Undifferentiated conditions Unscheduled care

Traditional functions must be refined and enhanced Active management of care transitions Integration with broader health system Value-driven care

Changing the approach to intermediate and complex conditions may result in significant cost-efficiency

Building early organizational capacity and capability is key Responding to changes Getting ahead of the curve Build a plan Start now

EMERGENCY MEDICINE IN HEALTH REFORM

ED-Focused Outcomes

e “F

RIGHT-SIZING THE ED ITSELF

Space and equipment

Provider staffing

Effective leadership

Quality Care▪ Acute treatment of sick and injured▪ Time-sensitive conditions▪ Rapid Diagnostic center▪ EMS direction and coordination▪ Disaster preparedness and response▪ Safety net care

Departmental efficiency▪ Input▪ Throughput▪ Output

FUNDAMENTALS & FOUNDATIONS

ED-Focused Outcomes

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Quality measure compliance

HCAHPS (and ED-CAHPS) performance

Readmission prevention

Two-midnight rule compliance

Hospital-acquired conditions (HACs)

Certification and regulatory standards

Care transition management

RIGHT-SIZING THE ED ITSELFRECENT CHANGES

ED-Focused Outcomes

e “F

A. CRITICALLY ILL, COMPLEX PATIENTS

B. LOW ACUITY PATIENTS

C. MODERATELY COMPLEX CONDITIONS

COMPLEX CHRONIC CONDITIONS

(clear hospitalizations)

(clear discharges to home)

(possible hospitalizations)

RIGHT-SIZING EMERGENCY CARETRANSITIONS INTO THE HOSPITALTRANSITIONS TO THE COMMUNITY

Examples: Multiple trauma STEMI Stroke Early identification of sepsis

Opportunities (keys to right-sizing): Agreed-upon care pathways Effective communication and transitions of care Quality measurement and optimization Utilization reviews Proper documentation Provider feedback

Efficient patient flow is still a high priority

RIGHT-SIZING EMERGENCY CARECRITICALLY ILL / COMPLEX PATIENTS

Examples: Upper respiratory infection Acute otitis Ankle sprain

Opportunities (keys to right-sizing): Clear discharge instructions Patient teaching Clear plan and referral for high value after-care Education about best use of health care options

(ED, primary care, urgent care, etc.)

Efficient patient flow is still a high priority

RIGHT-SIZING EMERGENCY CARELOW ACUITY PATIENTS

CHANGING THE APPROACH TO INTERMEDIATE & COMPLEX CONDITIONS

Hospital admissions account for approximately 31% of health care cost

Over half of hospital admissions come through the ED Intermediate and complex conditions account for 75-80% of these

admissions Examples: CHF, COPD, Diabetes, UTI, pneumonia, abdominal pain, chest

Hospitals can generate significant cost-efficiencies by addressing testing, treatment, and hospitalization patterns for intermediate and complex conditions These account for 31-57% of all ED visits Reducing hospitalization in this group by 10-25% would save 1-2.5% of

all health care costs ($28B - $70B annually)

* “A Novel Approach to Identifying Targets for Cost Reduction in the Emergency Department.”Smulowitz, Peter B., et. al.

Health Policy/Concepts, Annals of Emergency Medicine. 2012

Examples: Complex chronic conditions:

Congestive heart failure COPD Diabetic complications

Opportunities (keys to right-sizing): Identify high-frequency or high-risk groups Engage providers to determine care pathways Create alternative hospital-based resources, such as:

ED observation units Dedicated rapid treatment units Hospitalist or specialist consultation with in ED Consistently utilize the mechanism that delivers value & efficiency

Identify clinical and practical solutions to patient groups that require longitudinal care after ED treatment

Ensure seamless coordination of care and provider communication Plan for timely follow-up

RIGHT-SIZING EMERGENCY CAREMODERATELY COMPLEX CONDITIONSCHRONIC CONDITIONS Acute presentations:

Pneumonia Abdominal pain Atypical chest pain

Time, resources & space are required

Time-based throughput goals are a secondary priority

Diagnostic precision and care coordination is paramount

RIGHT-SIZING EMERGENCY CAREMODERATELY COMPLEX CONDITIONSCHRONIC CONDITIONS

At this time, do you think your ED should change its approach to intermediate and complex conditions?

A. Yes

B. Yes, but not now

C. Not now and probably not later, either

POLL QUESTION

OUTSIDE THE FOUR WALLS:PREPARING FOR THE FUTURE

Right-sizing patient care after the ED encounter Transitions of care Patient care follow up

Right-sizing utilization of the ED Best use of the health care system

OUTSIDE THE FOUR WALLSPREPARING FOR THE FUTURE

ED-Focused Outcomes

e “F

RIGHT-SIZING PATIENT CARE AFTER THE ED VISIT

Appropriate transitions of care

Care coordination

Case management and disease management (home monitoring, medication management, follow-up clinic, etc.)

Primary care (assignment, availability, appointment, visit assurance)

Other follow-up care (medication checks, etc.)

Palliative care

Telemedicine solutions

Use the ED as a “Canary in the Coal Mine” Early warning system Indicator of processes and resources needed to optimize value

ED-Focused Outcomes

e “F

Patient education on choosing site of care (in the context of local health care resources) Systems for managing care-seeking behavior Mutual efforts with employers and payors Managing high cost utilizers Deploying innovative solutions (telemedicine, etc.) Creating alternatives for low-acuity care that could be

managed in other settings ▪ Primary care

▪ Urgent care

▪ Options for uninsured

▪ Employer-driven options

RIGHT-SIZING UTILIZATION OF THE ED

Estimates of preventable ED visits vary widely (10-40% of all ED visits)

▪ Some rely on final diagnosis, rather than presenting condition

▪ Non-emergent visits cannot be reliably predicted based on presenting complaint (Raven, et. Al.)

Low-acuity visits still need medical care

▪ They also incur costs, which must also be considered

Even so, eliminating half of all ED visits for minor illness or injury results in saving only 0.2 – 0.8% of all health care costs. (Smulowitz, et.al.)

▪ Much smaller impact than intermediate/complex conditions

▪ Complicated by EMTALA mandate & prudent layperson standard

▪ Difficult management

WHAT ABOUT PREVENTABLE ED VISITS?

TAKE HOME POINTS

Take necessary time to address moderate complexity patients potentially requiring hospitalization.

This is perhaps the greatest near-term potential for enhanced value for the ED.

Requires:▪ Clear clinical strategies▪ Different processes in ED▪ Space▪ Sufficient staff

FAST CARE AT ALL COSTS FOR ALL PATIENT TYPES WON’T WORK ANYMORE

ATTEMPTING TO AVOID THE ED AT ALL COSTS IS UNLIKELY TO PRODUCE THE GREATEST VALUE

However, cost-efficient alternatives to ED care for certain conditions may be valuable for hospitals, health systems, and patients. Alternatives must be readily available, timely, and accessible. Alternatives must also coordinate care with other elements of the

system. If no timely or accessible alternatives exist, efficient utilization of

the ED is best, with concurrent patient education. Cost-efficiency requires scale, availability, and partnerships. Requires significant effort (and resources)

THE SAFETY NET FUNCTION OF THE ED MUST BE RECOGNIZED AND ACCOMMODATED

Most communities and delivery systems will continue to struggle with availability and access to primary care.

EMTALA requirements and the prudent layperson standard will continue to force cost-shifting. Lower reimbursing payers do not cover the cost of care.

Comparing the cost of ED care with other settings is difficult. Health care safety net comes at a cost. Standby and surge capacity comes at a cost. Capability for treating a large range of conditions comes at a cost.

Reinforces the need to leverage the ED’s fixed costs.

THE ED IS AN IMPORTANT SECONDARY HUB FOR MANAGING THE HEALTH OF POPULATIONS

Leverage the ED’s position at the interface of ambulatory and inpatient care.

When appropriately resourced, the ED can be a key setting for: preventing ambulatory care sensitive admissions and readmissions connecting patients to primary care

Forward-thinking organizations must embrace the role of the ED in bending the healthcare cost curve. Patients with the highest healthcare spending will end up in the

ED. Must build strong connections:

for hospitalized patients back to the ambulatory care continuum

Increasingly identified as a strategic asset for hospital-based care

Can be leveraged to address significant issues for hospitals and health systems

Must be: Effective in today’s environment Right-sized for the future Optimized for health care value in both

EMERGENCY DEPARTMENT

e “F

ED-Focused Outcomes

KEY DRIVERS OF CHANGE Value-based purchasing Novel payment mechanisms Cost management imperatives Fragmentation of care Insufficient access to primary care Emergency department crowding Overall reductions in revenue per

patient

QUESTIONS

Emergency Care and the Public’s Health Edited by Dr. Jesse Pines

A Novel Approach to Identifying Targets for Cost Reduction in the Emergency Department. Smulowitz, Peter B., et. al. (2012). Health

Policy/Concepts. Annals of Emergency Medicine.

Modern Healthcare Perspectives: Right-Sizing the Emergency Department in Health

Care Reform ModernHealthcare.com/Perspectives_Schumacher

ED Rapid Assessment Tool ed-assessment.schumachergroup.com

ADDITIONAL RESOURCES

RIGHT-SIZING THE EMERGENCY DEPARTMENT IN HEALTH CARE REFORMMODERN HEALTHCARE WEBINAR – OCTOBER 8, 2014

Webinar: Right-Sizing Your ED Amid Health Reform

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