THE HIGH ALERT PROGRAM:
HOW COORDINATED CARE PLANS FOR SPECIFIC ED PATIENTS
CAN BENEFIT PATIENTS, PROVIDERS AND HOSPITALS
Christopher Ziebell, M.D.
Emergency Service Partners, L.P.
Austin, TX
• Christopher M. Ziebell, MD, FACEP
– Emergency Service Partners, LP
High Alert Program Overview
• Introduction/Program Description
• Impact on Work Environments
• Evaluation/Results
What is the
High Alert Program?
• Case Management System
– Identifies Patients with Complex Needs
– Identifies Patients with Numerous ED Visits
– Organizes Clinical Information
– Creates a Plan for Future Patient Encounters
Evolution of the
High Alert Program
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SERT
Mechanism for filtering out high-utilizers
Behavior modification
Avoids pressure to triage out
Technology breakthrough
Database intervention and development
Narcotic termination letters
The Process
Patient Referral
Patient Chart Review
Treatment Plan Creation
Treatment Plan Implementation
Resource Requirements
for Program Development
Case
Management
Database
Social Work
Patient
Nursing
Director
IT Support
Administrator
Medical
Director
High Alert Levels
Level 4
Level 3
General Patient Population
Patients w/ Treatment Plan
Compassionate Dialysis • Sickle Cell • CHF
Level 2
Suicidal Patient
Level 1
Dangerous Patient
Examples of Cases
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Chronic Care Management
Gastric Bypass Patient
Sickle Cell Anemia
Heart Transplant
Fall Precautions
DNR
Management of Homeless Patients
SSI
Your Biggest Challenge?
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Patient Treatment History
Boundaries of Care
Development of the Care Plan
Identify Appropriate Resources
Staff and Patient Follow-up
What Does it
Take to Implement?
Sample Policy
• Sample Policy Exists
Relation to New Models
of Payment or Care Delivery
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Accountable Care Organizations (ACOs)
Medical Home
Quality Care
Cost Reductions
Hospital Re-admissions
Wellness and Prevention Emphasis
Personal Perception
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Faster
Lower Cost
Higher Quality
Lower Conflict
Medical Director Perspective
Eight reasons HAP is important to our
Emergency Departments:
8.Disciplined, standardized process
– Holds up to JCAHO/Legal Reviews
Old Model: “Winging It”
Key Processes:
Memory
PLAN
Rumor
Suspicion
Conflict
*Visit List*
Old Model: “Winging It”
Here last week!
Likes Dilaudid
Cousin in Jail!
Advantages:
• Easy
• Already in Use
Disadvantages:
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No Continuity
Poly-pharmacy
Liability
Inappropriate
Wasted Resources
New Model:
High Alert Program
Process:
• Referrals
• Multiple Inputs
• Research
• Social Work
• Case Management
• PCP
• Documentation
• Director Approval
• Re-evaluations
• Modifications
Advantages:
Many
Disadvantages:
Time-Consuming
Medical Director Perspective
Eight reasons HAP is important to our
Emergency Departments:
7.Increases physician job satisfaction
• Worth the costs of HAP
• Does not “tie the MD’s hands”
• Not “cookbook medicine”
Medical Director Perspective
Eight reasons HAP is important to our
Emergency Departments:
6.Improves the work life of our nurses
• Worth the costs of HAP!
• ED “hardest places to work”
• World-wide nursing shortage
• RN/MD partnership on treatment plan
Medical Director Perspective
Eight reasons HAP is important to our
Emergency Departments:
5.Involves the ED patients’ private MD
• Adds authority to care plan
• Engenders trust
• Suggests ramifications/consequences to
bad behaviors
He stole my cell phone last Friday!
Medical Director Perspective
Eight reasons HAP is important to our
Emergency Departments:
4.Improves quality of care
• Detailed synopsis of issues
• Necessary steps in workup
• Appropriate treatments
Just another OTD patient……
Medical Director Perspective
Eight reasons HAP is important to our
Emergency Departments:
3.Improves speed of care
• Avoids unnecessary calls
• Avoids unnecessary testing
Medical Director Perspective
Eight reasons HAP is important to our
Emergency Departments:
2.Exposes non-compliance
• 48 visits with nary a PCP visit
• 15 different dentist appointments in 1 year!
The care plan says you’re 4 minutes late
with my meds!
Medical Director Perspective
Eight reasons HAP is important to our
Emergency Departments:
1.Decreases conflicts and tensions
• Medical Director gets to be the heavy
• Patient / RN / MD all know the drill
• Defined endpoints for ED visits
Staff Survey
• Non-scientific poll
Survey
1…………
2…..…..…
• Effort to minimize bias
3……….….
• 10 questions; multiple-choice
• Sent via e-mail employing SurveyMonkey
• 39 doctors and 60 nurses responded
Staff Perspective
• Increases physician job satisfaction
SURVEY RESULTS
• 100% believe the HAP makes their
job easier.
Staff Perspective
• Improves the work life of our nurses
SURVEY RESULTS
• 75% believe the HAP makes their job
easier.
Staff Perspective
• Improves quality of care
SURVEY RESULTS
• 85% of MDs feel quality is improved
• 57% of RNs feel quality is improved
Staff Perspective
• Improves speed of care
SURVEY RESULTS
• 76% of MDs feel LOS is reduced
• 63% of RNs feel LOS is reduced
Staff Perspective
• Decreases conflict and tensions in the ED
SURVEY RESULTS
• 87% of MDs feel conflicts are reduced
• 50% of RNs feel conflicts are reduced
Overall Perspective
Brings a controlled & predictable process
to high-stress patient encounters within
a chaotic environment
Staff Opinion — VIDEO
Five Strategies for Reducing
Unnecessary Visits
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Chronic Care Management
Substance Abuse Screening
Off-Site Center for the Homeless
Primary Care Liaison
Collaborative Clinic
–The Advisory Board
This was written in 1993…
…You’ve come a long way Baby!
HAP Enrollments in Study
• Program active at several hospitals
• Studied: 7 hospitals with historical data
• HAP patients in study:
– 1,269 met inclusion criteria
(HAP patients with visit data within the study
interval)
Demographics
• 57% male
• Are much more commonly 20–40 than our
general population
HAP Patient Visits
Study Percentage of Selected Sites and Period
Time Frame for Data Collection 40 Months 12/2006 – 4/2010
Total # of Visits in Selected
HAP Sites over Period
100.0%
513,829
Total # of HAP Visits
2.3%
11,667
HAP Visits Excluded from
Sample
0.9%
4,791
HAP Visits in Study
1.3%
6,876
HAP Patient Visits
For 7 Selected Sites within Period
HAP Visits in Study
For 7 Selected Sites within Period
Site
Site A
Site B
Site C
Site D
Site E
Site F
Site G
Totals
All Visits
126,924
118,953
92,684
49,774
36,456
13,220
75818
513,829
HAP Visits % of Total
2.67%
2,041
3.62%
2,431
0.47%
247
2.20%
565
2.05%
567
0.97%
88
2.06%
937
1.34%
6,876
Interval Sampling-Definition:
“HAP Enrollment Interval”
• “Before and After” HAP enrollment intervals
were made for each individual patient
• Length of individual intervals were based on
patient enrollment date
• “After” HAP enrollment interval consisted of #
of days since patient’s enrollment to 5/1/2010
• “Before” interval is then set to equal number
of days prior to each patient enrollment
Interval Sampling
Patient A
Pre-Interval
Post-Interval
Enrollment Date
Patient B
Pre-Interval
Post-Interval
Enrollment Date
Study
Begins
Study
Ends
HAP Enrollments in Study
• Total HAP Visits in study: 6,876
• HAP visits before: 4,526
• HAP visits after: 2,350
• 48% reduction in number of visits
HAP Visits/Patient
Before vs. After Enrollment at Selected Sites Over Entire Period
# Patients Before
HAP Enrollment
# Patients After
HAP Enrollment
1 to 6 Visits
1,028
568
6 to 12
197
65
12 to 18
34
29
18 to 24
6
6
24 +
4
6
Totals
1,269
674
HAP Visits/Patient
Patients with 2 years of data (1 year interval before and after)
# Patients
Before
# Patients
After
1 to 6 Visits
278
134
6 to 12
137
44
12 to 18
25
26
18 to 24
6
5
24 +
4
3
Totals
450
212
HAP Population:
Top Ten Diagnoses
HAP Patients Visits in Selected Sites within Study Period
HAP Primary Diagnosis
LUMBAGO
HEADACHE
NAUSEA WITH VOMITING
SHORTNESS OF BREATH
ABDOMINAL PAIN-OTH SPEC SITE
NAUSEA ALONE
UNS CHEST PAIN
UNS BACKACHE
PAIN IN LIMB
UNS MIGRAINE WO INTRACTABLE MIGRAINE
Before
15.9%
14.7%
14.1%
10.2%
9.6%
9.1%
7.3%
6.6%
6.4%
6.2%
After
12.6%
12.2%
15.6%
11.5%
8.9%
10.4%
9.7%
5.8%
6.8%
General
6.41%
11.5%
11.7%
7.9%
Key Points re: Diagnosis
• Majority have a pain component
• Top 3 pain-related diagnoses had
percentage drop
• 4 of 10 Top Diagnoses follow general
population
Lab, CT, X-ray Utilization
Virtually unchanged
•2.5% increase in lab tests
•1% decrease in radiology
Services Utilized
1800
1600
1636
1504
1400
1200
1000
756
842
810
After
800
576
600
478
400
274
200
0
Neither
Lab Tests
Before
X-rays
Before: 4,526
Both
After: 2,350
Disposition
83.09% 82.46%
90.00%
82.26%
80.00%
70.00%
60.00%
Before
50.00%
After
Gen'l Pop
40.00%
30.00%
20.00%
14.56% 14.51% 14.19%
10.00%
0.42%
0.73% 0.32%
1.93% 2.30% 3.23%
0.00%
Admitted to Hospital
Admitted To ICU
Discharged
Transfer
Length of Visit:
Before vs. After
• LOV virtually unchanged
Financial Observation:
Professional Only
• HAP Before-Visits shows 11% reduction in
collections over general patient population
• HAP After-Visits shows same picture as
collection percentages of general patient
population
HAP “Before” Patients Payer Mix:
HAP vs. General Population
Payer
Difference
Charity
3.29% greater
Federal/State
4.79% greater
Self Pay
7.30% greater
Commercial
15.37% lower
HAP Visits Summary
At Selected Sites During Study Period:
• 48% reduction in number of visits
• 7.1% increase in number of visits in
general patient population at study sites
– using midpoint of study period
Soft Findings
• Decrease in variation and predictability of
outcome
• Results in increased patient safety (e.g.,
decreased radiation)
• Patients appreciate the fact that you know
them when dealing with complex needs
• Impact on Patient Satisfaction Scores
unknown
Hard Findings
• Reduced visits by 48%
• No improvement in the LOV data
• No change in percentage of patients to
receive Lab and X-ray, but actual drop in
line with drop of visits
• Payer Mix Changes after enrollment to
mirror general population
Example from Another
Health Care System:
• In the 12 mos pre-HAP (8/1/10-7/31/11),
76 patients had ≥ 11 ED visits  1046 total
visits
• In the 12 mos post-HAP (9/1/11-8/31/12),
the same 76 patients had 370 visits
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3 had more visits
1 had same visits
55 had fewer visits
17 had zero visits
• 64.6% reduction in ED visits
Does HAP Reduce Cost?
• Identified “Top 20” from 1 01, 2012 through 8
30, 2012.
• ED Case Manager reviewed the ED visit
history of each patient for patterns and
trends, noting PCP, if any, and type of
funding (majority unfunded).
Does HAP Reduce Cost?
• Case Manager and Medical Director reviewed
the “Top 20” list, devised patient-specific Care
Plans, and sent out notification letters to each
“Top 20” patient.
• Case Manager spent a great deal of time
coordinating outpatient care with private
physicians and community clinics specific to
each patient’s needs in order to reduce
unnecessary ED visits for non-emergent
problems.
Comparison of # Visits
9 mos pre-HAP vs. 4 mos post-HAP
40
35
4
30
20
15
10
5
13
3
25
7
2
31
0
21
2
0
2
0
0
1
3
1
2
2
1
0
14 14 13 13 13 12 12 12 12 12 12 12
11 11 11 11
475310
339683
380676
508998
324119
484546
601615
313164
601442
438400
415897
471950
607572
322297
478187
452904
605149
490323
0
4 mos post-HAP
9 mos pre-HAP
Comparison of ED Charges
9 mos pre-HAP vs. 4 mos post-HAP
0
200,000
400,000
600,000
800,000
1,000,000
9 mos pre-HAP
4 mos post-HAP
$642,652.63
$132,807.65
Comparison of ED Charges
9 mos pre-HAP vs. 4 mos post-HAP
(extrapolated out to 9 mos post-HAP)
0
200,000
400,000
600,000
800,000
1,000,000
9 mos pre-HAP
4 mos post-HAP
$642,652.63
$298,817.21
9 mos post-HAP
A Third Example
Quick look at reduction in ED utilization
among patients with repeated visits, after
HAP implementation, for site “A”
• In the 12 months January 1, 2010 through
December 31, 2010:
– 47 patients had 10 or more ER visits –
689 total visits (14.7 visits/pt avg)
A Third Example
• In the 12 months January 1, 2011 through
December 31, 2011:
– The same 47 patients had 353 visits or a 51.2%
reduction (7.5 visits/pt avg)
– 7 had more visits
– 39 had fewer visits
– 1 had zero visits
• This site has no case management support,
and the Medical Director does it all himself.
Questions and Answers