Reducing Preventable
Emergency Room Visits
June 15, 2012
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WSHA Presenters
Carol Wagner
Amber Theel
Senior VP,
Patient Safety
Director,
Patient Safety
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Presenters
Brigitte Folz, ACSW, LICSW,
Interim Director
Psychiatry and Behavioral Health
Ann Allen, Lead
High Utilizer Case Manger
Harborview Medical
Center
Harborview Medical
Center
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An Opportunity: Patients, when possible, should be treated by their
primary care provider for non-emergency conditions in order to promote
consistent, quality care helping protect physician/hospital payments.
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By June 15, 2012 hospitals must have implemented best practices on:
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Electronic health information
Patient education
High-user client information/identification
High-user client care plans
Narcotics prescriptions
Prescription monitoring
Use of feedback information
By January 1, 2013 hospitals must demonstrate reduction in low acuity visits
If unsuccessful, physicians and hospitals will suffer major cuts in Medicaid ER
payments
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Partnering for Change
• Washington State Hospital Association
• Washington State Medical Association
• Washington Chapter of the American College
of Emergency Physicians
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Emergency Room Overuse:
It Is a Problem
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Medicaid ER Use Is High
In the past year:
• About 40% of Medicaid clients visited an ER
• About 18% of people with private insurance
visited an ER
Contributing factors:
 Lack of primary care
 Substance abuse
 Mental health
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Mental Health
• In the last decade emergency departments
have seen a dramatic rise in the presentations
for mental health related issues.
• In 2007, 3.2% of presentations to emergency
departments were mental health related, this
is over 190,000 presentations.
• Mental health issues are often complicated by
substance abuse
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Barriers
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Poor historian
High anxiety
Lack of resources (housing, medication etc.)
High incidence of substance abuse
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UW MEDICINE
PATIENTS ARE FIRST
HIGH UTILIZER CASE
MANAGEMENT PROGRAM
WSHA WEBCAST – JUNE 2012
HIGH UTILIZER CASE
MANAGEMENT TEAM
• Since 2009 this HMC, Regional Support Network, and MIDD-funded
program has provided prevention, intervention, and linkage for
Emergency Department high utilizers
• The case managers provide assertive outreach and engagement for a
designated high utilizer caseload.
• Individuals receive intensive services, including intensive outreach and
advocacy to provide linkage for housing, chemical dependency, mental
health, and medical follow-up.
• Current HUP Case Management team consists of:
 1 Mental Health Practitioner Lead
 2 Mental Health Practitioners
 1 Program Assistant: staff support shared with another contract funded
project.
• Reached full capacity in August of 2009.
CM PRINCIPLES AND
INTERVENTIONS
• Program is based on successful
UCSF ED Case Management
Program
• Harm reduction approach to CD
issues
• Motivational strategies
• Assertive efforts to engage patient
• Networking with agencies to
in ED and in the community
provide continuity of care
• Respectful and compassionate care
• Close team communication and
• Relationship building in the field
supports
 Shelters, parks, freeway ramps,
agency waiting rooms, fast food • Client self determination and care
planning
restaurants, buses
• Concrete resource provision – food • Network care conferences
vouchers, bus tickets, etc.
MEASURING IMPACTS
• Up to 30 active patients on the program caseload at
any given time
• Expected LOS is 3 months
• HMC Decision Support identifies and provides ED
high utilizer data
• Number of ED visits and cost associated are collected
• Early data showed a decrease in jail admissions
• First year results showed a 67% reduction in ED visits
• Newer data shows a 50% reduction and also
significant inpatient admission reduction
CASE PROFILE
• High utilizer criteria: 4 ED visits in a six-month period
• Homeless or in danger of losing housing
• Lack of effective engagement or alienation from
traditional resources
• Increasing inability to cope with street life due to medical
concerns
• Most clients have concurrent mental health, chemical
dependency, and medical concerns
• Most common linkage needs: funding, primary care,
chemical dependency treatment, mental health
treatment, and housing
• Housing need is a huge barrier to long term stability
CASE STUDY #1
• ~50 y. o. man
• Homeless
• Chemical dependency –
primarily alcohol
• Increasing medical problems
with multiple ED visits for
cellulitis and withdrawal
seizures
• Legal issues
• Interventions:
 Assertive outreach and
engagement
 Supported housing
 Bus tickets
 Aggressive networking of
supports
• Key network linkages:
 Reach
 Seattle Indian Health Board
 DSHS - NA outreach worker
 Chemical Dependency
Involuntary Treatment
Services
 Supported housing
 KC Detox
• Now sober, stable housing,
reconnected to family and
native community
CASE STUDY #2
• ~40 year old man
• Multiple medical problems including diabetes and chronic back
pain with non-compliance with medications and physical therapies
 Alcohol dependent
 Depressed
 In danger of losing his housing
• Enrolled in mental health but not engaged; case manager engaged
in medical advocacy.
• Intervention
 Care plan developed to include time management, motivational
interviewing, and communication skills as well as focus on
behavioral positive reinforcement.
• Now patient is increasingly engaged with his mental health
providers, returned to physical therapy, actively managing his
diabetes. Working on his CD issues (not yet clean). He was able to
retain his housing.
SPECIALIZED CLINICAL
INTERVENTIONS
• Care plans
• Case review – network planning
• Outreach and engagement in the community
• Crisis case-management
• Social services focused interventions
• Harm Reduction
• Advocacy stance
CASE REVIEW PROCESS
• Community Collaboration to engage and plan for
patient services
• County Organized Coalition: High Utilizer Group
• Data sharing
• Assigning roles
• Community Ownership of the Care plan
Outcomes suggest that after collaboration use
decreases for 60% of individuals
ED PATIENT CARE PLAN
EXAMPLE
1) Issue: ______________with a history of high utilization of multiple EDs, health care
systems. Pt has a hx of calling 911 seeking assistance which frequently turns out to
be anxiety related…………
2) Key Health Concerns:…….
Most frequent urgent complaints include:…….
Other Health Concerns:…………
3) Professionals Involved in Patient’s Care: Pt currently has a stable Primary Care
Physician for the past 24 years is ______________Pt’s primary hospital is
______________…………. Pt is currently on a Review and Restriction Program from
DSHS. Ann Allen, HMC High Utilizer case manager (206) 744-5838.
4) Action Needed/Suggested: The emergency department can provide screening
evaluation to determine her need for treatment any emergent medical condition. She
responds best to one on one reassurance and choices rather than
limits…………………… For example………..
This care plan was created in consultation with her primary care physician_______
LIFE IS COMPLICATED
Medical Care
Mental
Health
Funding
Criminal
Justice
Housing
Chemical
Dependency
ED VISIT DATA PER
PATIENT: YEAR 1
ED Visits by Individual Pre and Post Case Management
35
30
Many patients had
no ED visits after
case management.
25
20
15
10
5
0
34 Individuals in Case Mgmt Program
Pre CM ED Visits
Post CM ED Visits
PRE- AND POST-SERVICES
COMPARISON: ED CHARGES
6,000,000
Total Charges and ED Charges
(Most recent data)
pre-case total charge,
5,322,592
5,000,000
4,000,000
3,000,000
post-case total
charge, $2,337,969
pre-case charge_ED,
1,612,429
2,000,000
post-case charge_ED,
$833,168
1,000,000
0
pre-case total charge
pre-case charge_ED
post-case total charge
post-case charge_ED
2012 RESULTS
Average ED Visits Per Client Per Month
2.00
1.80
1.60
1.40
Pre-Case, 1.25
1.20
1.00
0.80
0.60
0.40
0.20
0.00
Post-Case 0.68
REDUCTION IN ED AND
INPATIENT VISITS
700
Pre & Post CM: Patient Visit by Type
OUT, 632
600
500
400
OUT, 329
300
200
INP, 140
100
INP, 56
0
Pre_case
Post-case
IN CONCLUSION
• High risk of morality in cohort (substance
abuse and chronic illnesses)
• Opiate and benzodiazepine dependence
• Community mental health services found to
be a willing partner
• Chronic substance abuse and long term care
challenges
• Information sharing via High Utilizer ROI
• Housing, housing, housing
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PROGRAM CONTACTS
Brigitte Folz, LICSW
(206) 744-4052
ebgf@uw.edu
Ann M. Allen, LICSW
(206) 744-5838
annall3@u.washington.edu
What are the three top priority
strategies that hospitals could use to
make the biggest impact now?
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Quick Action Needed!
Hospitals must
submit
attestations and
best practice
checklists to HCA
by June 15, 2012
Looking for the last handful of hospitals to
send their attestations in.
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Best Practices Just First Step
• HCA will perform a preliminary fiscal analysis
and report to the legislature by January 2013
• Hospitals need to demonstrate a reduction in
emergency room visits
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If Unsuccessful
Revert to the
no-payment policy.
$38 million in
annual cuts!
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Ongoing Oversight and Measurement:
Emergency Department Workgroup
• Health Care Authority
• Washington State Chapter of the
American College of Emergency
Physicians (WA/ACEP)
• Washington State Medical Association
• Washington State Hospital Association
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Questions and Comments
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