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Week 7 Change Project Recommendation
Lauren Rogers
Wilmington University
MSN 6608 Evidence Based Practice in Health Professions
Amy Drennan
May 1, 2022
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Week 7 Change Project Recommendation
The problem of inappropriate use of the Emergency Department (ED) is not unique to the
United States. Studies and articles discussing this issue were found with research conducted
worldwide. Various payment methodologies were also discussed, including capitation models in
which primary care providers (PCPs) are paid a predefined rate per member per month. As such,
managing care generally results in savings, while unmanaged care may result in increased
expenses and reduced net profits by the providers. Szwamel and Kurpas (2019) proposed that
capitated reimbursement did not lend to decreased ED utilization (p. 171). Rather, they proposed
that providers reimbursed under capitated contracts had a reduction in patient satisfaction and
subsequent increase in inappropriate utilization of the Emergency Department.
PICOT
This PICOT for this paper is: in patients with non-urgent health conditions, how does an
increase in access to primary care providers, versus no increased access to primary care, affect
Emergency Department utilization over a six-month period of time?
Proposed Solution
This writer proposes that providers associated an Accountable Care Organization (ACO)
receive incentive pay for patients seen after 5 p.m. in the primary care office. Hong (2021)
found that this incentivizing led to a decrease of non-urgent ED usage by 1.16 visits per 1000
patients per month (p. E 85). Timmins, Peikes and McCall (2020) reported similar findings, a
2% decrease in inappropriate ED usage when patients had access to same-day and next-day
primary care appointments (p. 1003).
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Resources
To accommodate this increased patient load, additional providers will need to be
recruited and hired, with all providers rotating coverage of the evening hours. The additional
providers necessary to cover evening hours will eliminate the chance for decreasing daytime
bandwidth and negatively impacting the outcome of the project. Providers must be hired, and
office staff must either be added or existing staff required to work overtime with rotation for the
evening and weekend coverage.
Training must be completed for all staff responsible for managing the phones and triaging
patients. This includes office assistants, medical assistants, and nursing staff. These support
roles are key in directing traffic. By providing guidance and training on the types of conditions
to be managed in the office versus requiring care in the Emergency Department, these critical
support staff will prepared to schedule an after-hours appointment with a provider instead of
sending the patient to the ED.
After staffing is secured and training is completed, patients must be notified of the
expanded hours. This may be accomplished via post card mailers, messages played while callers
are placed on hold, and by signage in the primary care offices.
Budget
The budget for this project includes expenses incurred by the Accountable Care
Organization and those incurred by the primary care practices.
The Accountable Care Organization will budget a 15% increase in Fee For Service (FFS)
reimbursement for all visits made by primary care providers (physicians, osteopaths, nurse
practitioners and physicians assistants) after 5 p.m. on weekdays and any time on weekends. It is
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expected that the increased expenses will be offset by cost savings as Emergency Room usage
declines, but the savings shall not be factored into the budget.
The primary care providers will budget increased expenses in provider Full Time
Equivalents (FTEs) to accommodate the increased after hours and weekend bandwidth.
Additional FTEs must be allotted for supportive staff, both office assistants and medical
assistants, as well as nurses, if required. This should have a neutral impact on operating
expenses, as patient visits have a Fee-For-Service reimbursement model. There will be a
positive impact on income with the increased bandwidth and further increase in revenue with the
15% FFS incentive for after hours and weekend visits.
The budget must also include the nominal cost for mailers, signage, and messages to be
played for phone callers on hold. It will also include one-hour training for all office support
staff.
Method of evaluation
To evaluate the effectiveness of the proposed changes associated with this project, data
must be collected and analyzed. The emergency department will create a system to classify
utilization, denoting visits that were for non-urgent conditions appropriate for treatment by the
primary care provider. This data will be collected for six months prior to implementation,
creating a baseline for ED utilization. The project committee will determine a target for success,
whether that be volume based, savings based, or a combination of both.
After project implementation, the ED will continue data collection to determine
utilization rates for non-urgent conditions. For conditions appropriate for evaluation in a nonurgent care setting, the patient will be asked if they first called their provider to obtain an
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appointment. If not, why not? If so, did they choose the ED due to lack of provider bandwidth
or because the provider directed them to the ED?
Data will also be collected regarding primary care visits. Did the evening and weekend
scheduling increase the volume of visits, or simply shift the existing volume to after hours?
Data collected after project implementation will be reviewed and compared to targets to
determine project success.
Benefits to implementation of new practice
If the project is successful, two things will occur. First, the numbers of Emergency
Department visits for non-urgent conditions will decrease while the volume of primary care
provider visits will increase. Secondly, the satisfaction of patients seen in the ED and those
obtaining care from the primary care providers will increase. ED patients should have increased
satisfaction as wait times decrease, and primary care patients should have increased satisfaction
with increased access to care.
Limitations
Challenges to this project include the lack of provider ability to be a “one stop shop”; that
is, providers do not have the ability to complete the diagnostics available in the ED. This lack of
ability may influence patients who desire to have all care and tests provided at once. To
compensate, increased bandwidth for same or next day testing must be realized whenever
possible to allow for patients to receive the appropriate diagnostics as timely as possible.
Another challenge is that Accountable Care Organization (ACO) has no control over
patients seeking care in non-affiliated Emergency Departments. As such, there is limited
visibility into that segment of patients receiving ED care outside the health system, so data will
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never be 100% accurate; it will be skewed by care received in outside Emergency Departments
where there is no data collection.
Conclusion
Decreasing inappropriate use of the Emergency Department for non-urgent conditions is
an essential component of cost containment and managing resources wisely and effectively.
Additionally, expanding after hours primary care improves patient satisfaction through decreased
wait times in the ED and increased access to primary care without requiring patients miss work
or school. If this project is successful, both outcomes will occur.
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References
Szwamel, K., & Kurpas, D. (2019). Assessment of the health care system functioning in Poland
in light of the analysis of the indicators of the hospital emergency department (ED) and
primary health care (PHC) – proposals for systemic solutions. Family Medicine &
Primary Care Review, 21(2), 164-173. DOI: 10.5114/fmpcr.2019.84553
Hong, M. (2021). Emergency department use following incentives to provide after-hours primary
care: a retrospective cohort study. Canadian Medical Association Journal, 193(3), 85.
DOI: 10.1503/cmaj.200277
Timmins, L., Peikes, D., & McCall, N. (2020). Pathways to reduced emergency department and
urgent care center use: Lessons from the comprehensive primary care initiative. Health
Services Research, 55(6), 1003-1012. DOI: 10.1111/1475-6773.13579