Washington State Best Practices
Update Fall 2012
Dr. Stephen H. Anderson, MD, FACEP
Dr. Nathan Schlicher, MD, JD, FACEP
Dr. Darin Nevin, MD
Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
The State Budget
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Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
Health Care Portability Act of 1996
• You have the right to access emergency
services 24 hours a day. By law, a situation is
considered to be an "emergency" if a prudent
layperson believes that failing to act
immediately would put your health or the
health of others in danger.
Both State & Federal legislative
protection for insured & managed
care patients…
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Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
The Seven
Best
Practices
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Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
A) Electronic Health Information
Goal: Exchange patient information among
Emergency Departments
• Identify frequent users
• Get access to treatment plans
• Use in providing care
• Exceptions for CAHs with
financial burden
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Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
B) Patient Education
Goal: Help patients
understand and use
appropriate sources of care
• Active distribution of
educational materials
• WSHA/WSMA/ACEP brochure
• Discharge instructions
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Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
C) Patients Requiring Coordination
(PRC) Information
Goal: Ensure hospitals know when they are
treating a PRC patient and treat accordingly
• PRC clients = frequent ER users, often narcotic
seekers
• Receive and use client list
• Identify patients on arrival
• Develop and coordinate case
management programs
• Use care plans
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Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
D) PRC Client Care Plans
Goal: Assist PRC clients with their care plans
• Contact the primary care provider when PRC client
visits the ER
• Efforts to make an appointment with the primary
care provider within 72 hours when appropriate
• If no appointment required, notify primary care
provider that a visit occurred
• Relay barriers to care to Health Care Authority
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Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
F) Prescription Monitoring
Goal: Ensure coordination of prescription drug
prescribing practices
• Enroll providers in Prescription Monitoring Program:
electronic online database with data on patients prescribed
controlled substances
• Target enrollment for ER providers :
– 75% by June 15, 2012
– 90% by December 31, 2012
– Enroll is one thing… USE is another!
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Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
G) Use of Feedback Information
Goal: Review reports, ensure interventions are
working
• Report specified information to Health Care
Authority
• Designate ER leader and quality manager to
receive, review, and act on utilization
management reports
• Involve executive-level leadership
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Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
Managing Difficult Conversations
Social Psychology 201
For ED’s
Stephen H. Anderson M.D., FACEP
President, WA State Chapter ACEP
Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
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I Think You Have A
Drug/ Alcohol Problem
Society/ Legislature/ Peers now tell us
We MUST have these conversations
THIS is the pivotal time.
Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
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Drug & Alcohol Problems
The Principles
• There are rules/ guidelines
• Listen first
• Your allies/ their allies
“Their support” might turn out to be your best ally!”
• WIN-WIN
• Be true to yourself
Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
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Drug & Alcohol
Tools to Help
• Old Records
• EDIE
• WA state Prescription Monitoring Program
Educate patients that these exist
Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
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I Think You’re Here Too Often
PRC
Patients
Requiring
Co-ordination
Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
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You’re Here Too Often
New WA Hospital Requirements
• Identify PRC clients upfront
• Notify their PCP of visit
• Discharge patient with instructions along:
“the right patient-to the right place-at the right time”
Shouldn’t be a punitive discussion
Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
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Warning!
Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
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Nathan Schlicher, MD, JD
Legislative Affairs Chairman, WA ACEP
Associate Director, St. Joseph’s MC ED
Associate Director, TeamHealth PSO
Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
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5000
4500
All State ED Visits

ED visit rate per 1000 Medicaid clients
4000
3500
3000
2500
Total
2000
1500
1000
500
0
201101201102201103201104201105201106201107201108201109201110201111201112201201201202201203201204201205201206
Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
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SJMC Medicaid Visits

Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
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PRC Visits with
Narcotics

Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
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Average Pills per Script

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Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
Pills per Script

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Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
Takeaway Points

 We are doing well overall
 One of the best on pills per scripts
 Room to improve on PRC folks
 Fewer narcotics
 State improving, must continue to climb
Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
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Darin Neven, MS, MD
Providence Sacred Heart Medical Center and Children’s
Hospital
Spokane, WA
darin@darinneven.com
www.consistentcare.com
Draft ED Care Plan
Standard

Header Information
– Date Plan First Created
– Date Plan Last Updated
Security Alert
Pain Contract and
Scheduled Prescribing
Draft ED Care Plan Standard

Primary Care Provider and
Specialist
• Past Medical and Surgical
History
• Substance Use and Abuse
History
• Mental Health Conditions
Optional (Phase 2)

Optional sections, may be made mandatory
later.
•
•
•
•
•
Barriers to Care Delivery
Radiation Alert
Overdose Alert
Special Care Recommendation
Details
New Initiatives

 Protect Providers from False Complaints
 Prescribed Naloxone
 www.prescribetoprevent.org
Best Practices Are a Foundation
If we are serious
about achieving this:
Projection
Actual trend
Hospitals and
emergency
physicians need to
be looking for
trends and patterns,
intervene, make
continuous change!
Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
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Best Practices 2.0 ?
• Access to follow-up primary care
• Access to dental health care
• Reimbursement incentives for same day
scheduling of PRC clients
• Accountability to Health Care Systems for
coordination of care
• Persistent pressure for Tort reform to decrease
costs of “defensive medicine”
Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
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BEWARE!
Newest Twist in HCA rules, July 2012
(13) Client financial responsibility
” A client placed in the PRC program may
be billed by a provider and held financially
responsible for health care services when
the client obtains non-emergent services
and the provider who renders the services
is not assigned or referred under the PRC
program.”
Presented at WSHA Safe Table – ER is for Emergencies 9/24/12
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Questions?
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