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The Emergency Department (ED) is often at the center of some of the most controversial issues in health care reform. The cost of care, coordination of care, avoidable hospitalizations, misuse of the ED, and other issues have challenged hospitals to keep costs under control while delivering timely access, efficiency, and quality. Today's challenges certainly create an imperative for change. But more importantly, hospitals must respond to a rapidly evolving health care environment, where the typical approach may not only become obsolete, it may be perilous. Preparing for the future will require substantial changes. An accurate “diagnosis and treatment plan” is essential. And getting this “right” matters.
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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
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PRESENTERS
RIGHT – SIZINGTHE EMERGENCY DEPARTMENTIN HEALTH CARE REFORM
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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
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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:
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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
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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
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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?
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“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
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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
Expa
nded
ED
func
tions
Com
ing
Soon
: B
eyon
d th
e “F
our W
alls
”C
ore
ED F
unct
ions
ED-Focused Outcomes
The Emergency Department as a Value-Driven Asset
© 2014
Key Hospital Outcomes
Value-Driven Health System
Coordination & Continuity
Evolving Care• Treatment of intermediate conditions• Treatment of complex chronic conditions
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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
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RIGHT-SIZING THE ROLE OF THE EMERGENCY DEPARTMENT
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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
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Foundations• Acute treatment of sick & injured• Treatment of time-sensitive conditions• Rapid diagnostic center• EMS direction and coordination• Disaster preparedness & response• Safety-net care
ED-Focused Outcomes
The Emergency Department as a Value-Driven Asset
© 2014
Key Hospital Outcomes
Value-Driven Health System
Coordination & Continuity
Expa
nded
ED
func
tions
Com
ing
Soon
: B
eyon
d th
e “F
our W
alls
”C
ore
ED F
unct
ions
15
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
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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
ED-Focused Outcomes
The Emergency Department as a Value-Driven Asset
© 2014
Key Hospital Outcomes
Value-Driven Health System
Coordination & Continuity
Expa
nded
ED
func
tions
Com
ing
Soon
: B
eyon
d th
e “F
our W
alls
”C
ore
ED F
unct
ions
17
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
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ED-Focused Outcomes
The Emergency Department as a Value-Driven Asset
© 2014
Key Hospital Outcomes
Value-Driven Health System
Coordination & Continuity
Expa
nded
ED
func
tions
Com
ing
Soon
: B
eyon
d th
e “F
our W
alls
”C
ore
ED F
unct
ions
Evolving Care• Treatment of intermediate conditions• Treatment of complex chronic conditions
19
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
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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
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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
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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
pain
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)
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* “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
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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
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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
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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
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OUTSIDE THE FOUR WALLS:PREPARING FOR THE FUTURE
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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
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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
ED-Focused Outcomes
The Emergency Department as a Value-Driven Asset
© 2014
Key Hospital Outcomes
Value-Driven Health System
Coordination & Continuity
Expa
nded
ED
func
tions
Com
ing
Soon
: B
eyon
d th
e “F
our W
alls
”C
ore
ED F
unct
ions
29
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
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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
ED-Focused Outcomes
The Emergency Department as a Value-Driven Asset
© 2014
Key Hospital Outcomes
Value-Driven Health System
Coordination & Continuity
Expa
nded
ED
func
tions
Com
ing
Soon
: B
eyon
d th
e “F
our W
alls
”C
ore
ED F
unct
ions
31
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
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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
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WHAT ABOUT PREVENTABLE ED VISITS?
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3434
TAKE HOME POINTS
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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
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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)
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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.
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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
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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
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41
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
Expa
nded
ED
func
tions
Com
ing
Soon
: B
eyon
d th
e “F
our W
alls
”C
ore
ED F
unct
ions
ED-Focused Outcomes
The Emergency Department as a Value-Driven Asset
© 2014
Key Hospital Outcomes
Value-Driven Health System
Coordination & Continuity
Evolving Care• Treatment of intermediate conditions• Treatment of complex chronic conditions
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
41
QUESTIONS
42
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
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RIGHT-SIZING THE EMERGENCY DEPARTMENT IN HEALTH CARE REFORMMODERN HEALTHCARE WEBINAR – OCTOBER 8, 2014
