Results of ED Utilization Analysis and
Initiatives Questionnaire
June 8, 2011
Presented by:
Howard Pitluk, MD, MPH, FACS, Vice President/Chief Medical Officer
Margaret deHesse, RN, BSN, Executive Director State and Corporate Services

Plans Who Provided Data
HMO
Humana, Inc.
Medica Health Plans of Florida
Better Health, LLC
Molina Healthcare of Florida
Freedom Health (Freedom 1 st )
UnitedHealthcare Community Plan
Universal Health Care
PSN
Sunshine State Health Plan
First Coast Advantage
South Florida Community Care
Network
Children’s Medical Services
Network Duval
Children’s Medical Services
Network Broward

ED Utilization Analysis
11
12

When was the Analysis Completed?
1
1
3
7
2011 2010 2009 Never

Did the analysis include identification of visits to the ED that could have been treated by the PCP?
Yes
5
6
No
None of the plans used the New York University (NYU)
Algorithm for the ED analysis

URI
Viral Syndrome
Sore Throat
Croup/Cough
Otitis Media
Gastroenteritis
Asthma
Low Back Pain
Dental
Fever
Pharyngitis
Abdominal Pain
UTI
Vomiting
Ear Pain
Rash
Conjunctivitis
Constipation
Allergic Rhinitis
Insect Bite
Top Conditions of Avoidable ED Visits
South Florida - PSN Medica - HMO
X
X
X
X
X
Universal
X
X
Sunshine - HMO
X
X
X
X
X
X
X
X
X
X
X
X
X
CMS Duval - PSN
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X

Observations of ED Analysis by
HMOs/PSNs
 A small percentage of members account for a high percentage of ED use (ultra utilizers)

Majority of visits for members < 21 years of age

Majority of visits for members 0-5 years of age

Did the Analysis Identify Ultra Utilizers?
3
8
Yes No

Conditions of the Ultra Utilizers
Each of the following was identified once by the plans as a Top Ten diagnoses of the Ultra Utilizers
Sickle Cell Disease Behavioral Health
Issues
URI Otitis Media
Utilizers by just one plan:
Diabetes Spinal Stenosis
Rash
Head Injury
Sore Throat
UTI
Abdominal Pain
Fever
Gastroenteritis/Colitis
Diarrhea
Digestive
Bronchitis
Symptoms , Signs, and Ill defined conditions
Viral Infection
Headache
Diseases of the
Nervous System and
Sense Organs

Current Initiatives

Member Education and Outreach –

Welcome packets - Location of urgent care centers

Use of 24/7 nurse line
 Reminder letter to schedule appointment with PCP
 Educational materials on ED use

Encourage linkage to PCP

Assist member with changing PCPs

Current Initiatives

Case Manager/Health Coach -

High utilizers – Refer to case/disease management

Assist members with scheduling PCP appointments

Behavioral health co-management

Health coach – Real time follow-up

Provider Education and Outreach –

Educate providers about urgent care options

Notification of member ED use

Notification of high opiate use

Current Initiatives
 Emergency Department
 Daily/ Weekly ED Census

Work with ED Staff to conduct a face-to-face meeting with member and perform an ED assessment

Current Initiatives - Evaluation

Sunshine State –
 90 percent of members stopped going to the ER
 10 percent still use multiple times
 Greater than 40 percent decrease in ER usage overall

Universal -

Results showed a decrease in ED usage for the pilot county

Current Initiatives - Evaluation
 Humana -

Pre-evaluation ED usage of the entire population - 5.5

Post evaluation usage - 4.9

Pre-evaluation of members who had interventions - 7.4

Post intervention - 2.3

6
5
4
3
2
1
0
Daily Census from EDs
6
5
Yes No

Methods of Receiving Census
Type
HMO Sunshine State
Name
Fax
Method
HMO Humana
HMO Medica
HMO UnitedHealthcare
N/A
N/A
Fax
HMO Freedom Health-Freedom 1st N/A
HMO Molina Healthcare
PSN Better Health LLC
PSN CMSN Broward
PSN CMS Duval
N/A
Method unknown
Self-run report
N/A
PSN First Coast Advantage Hospitals email and fax daily ED census
PSN South Florida Community Care Self-run report

24/7 Nurse Advice Line
7
6
5
4
3
2
1
0
5
7
Health Plans
Have a Nurse Line Do Not Have a Nurse Line

Nurse Advice Line Usage
•
4
HMO/PSNs have a
24/7
Nurse Advice Line for members
Type
HMO Sunshine State
Plan
Less than 1%
Usage
HMO Humana
HMO Medica
HMO UnitedHealthcare
HMO Freedom Health-Freedom 1st N/A
HMO Molina Healthcare Less than 5%
HMO
PSN
Universal
Better Health LLC
No response
No response
PSN
PSN
CMSN Broward
CMSN Duval
Not sure of exact percentage but it is probably low
N/A
No response
N/A
1% (Behavioral Health only)
PSN First Coast Advantage N/A
PSN South Florida Community Care N/A

Care from Non-PAR Providers
Type
HMO
HMO
HMO
HMO
HMO
HMO
HMO
PSN
PSN
PSN
PSN
PSN
Sunshine State HP
Plan
Humana
Medica
UnitedHealthcare
Freedom Health-Freedom 1st
Molina Healthcare
Universal
Better Health LLC
CMSN Broward
CMSN Duval
South Florida Community Care
First Coast Advantage
Less than 1%
Response
Not known but probably low
6.1% (285 members)
Unknown
Unknown
Less than 5%
Unknown
Minority of members
20%
7.90%
20%
32.7 %

Considerations for the ED Collaborative
 Member -
 Need member education on treating minor ailments

Real time outreach is effective

High illiteracy rate - welcome packets of little benefit

ED -

Lack of communication between EDs
 EDs advertise low wait time

Considerations for the ED Collaborative
 Other
 Use mobile diagnostic units for preventive services

High volume of ED use at non-contracted facilities

No link between mental health vendor and MCP regarding
ED use driven by mental, alcohol and substance abuse disorders
 Underlying diagnoses in children often make ED visits the correct choice
21

Behavioral Health
How are members with Behavioral Health conditions who access the ED tracked?
4
3,5
3
2,5
2
1,5
1
0,5
0
4 4 4
Tracked by HMO/PSN Tracked by Vendor Not Tracked
22

23

Overview

Structure

Statewide Collaborative (IMPROVE)

Five Regional Steering Committees

Patient Streams

Ultra Utilizers: Mental Health, Non-mental Health,
Chronic Back Pain

Dental
 URI - Statewide
24

Ultra Utilizers Intervention

High utilizers are identified as sample members.

Interdisciplinary Teams develop care treatment plans to establish a coordinated care approach. The goal is to meet the sample members’ needs and re-direct them to their medical home rather than the ED.
 Sample members are flagged at participating EDs.

If a member in the sample accesses the ED, the attending ED Physician will:

Reference the care plan summary, and
 Notify the Interdisciplinary Team contact person that a sample member has accessed the ED.
 The Interdisciplinary Team continually outreaches sample members and coordinates care to reduce avoidable ED visits.
25

NORTHWEST REGION – BACK PAIN
Emergency Departments
Toledo Hospital [ED]
TEST SITES
T OTAL PATIENTS IN TEST INTERVENTION
= 13
Mercy St. Vincent [ED]
University of Toledo [ED]
Mercy
St Vincent
Pain Clinic
Care Treatment Plan Contact: Clinic Manager
Integrated Care Team
Managed Care Plans
(MCPs)
Buckeye
(5 Sample Patients)
Case Managers
Care Source
(5 Sample Patients)
Case Managers
Unison
(3 Sample Patients)
Case Managers
26

Dental Intervention
Business Hours
 Medicaid managed care members presenting with dental conditions are identified at the ED.
 EDs call participating dental providers and secure a fast-tracked dental appointment for the patient.
 EDs forward the identifying information of sample patients to the appropriate MCP.
 MCPs follow-up with the member.
After-Hours
 ED staff distribute a card listing the MCP contact information and instruct the patient to call the MCP during business hours for a fasttracked dental appointment.
27

URI Intervention
1.
Sample members receive a kit for colds which promotes the managed care plans’ (MCP) 24-Hour Nurse Advice Line with a “call early, call often” theme

Most sample patients receive the kits through the mail with a letter from their primary care physician (PCP) or their health plans’ medical director. In the real-time test interventions, kits are distributed at the ED.
2.
MCP Nurse Advice Lines triage sample members and bridge services the
MCP has to offer with follow-up PCP care
3.
PCP office provides next day/same day appointment scheduling for sample members
4.
An MCP Health Coach follows-up with members in the test intervention sample
28

29