Reducing Unnecessary
Emergency Room Use:
Best Practices
1
WSHA Presenters
Scott Bond
Claudia Sanders
Chief Executive Officer
Senior VP,
Policy Development
Carol Wagner
Barbara Gorham
Senior VP,
Patient Safety
Policy Director,
Access
2
Partner Presenters
Washington State
Medical Association
Tim Layton
Washington Chapter American
College of Emergency Physicians
Dr. Stephen
Anderson
Dr. Nathan
Schlicher
3
Webcast Objectives
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Overview
Emergency room overuse: a significant issue
History
The seven best practices
A fast timeline!
How we can help
Questions and comments
4
An Opportunity
Redirecting Care to the Most
Appropriate Setting
5
Health Care is Changing
• Work with the state and partner physicians
• To be sustainable in the long term:
– Adequate payment
– Cost reduction
6
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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One client:
Frequent Users
All clients:
Focus on Patients Requiring Coordination (PRC)
Enrollees per county
.
009
.005
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Is the ER the new medical home
of the 21st century?
Legislative Solutions
13
State Approaches to Curbing ER Use
When
Original
proposal
Revised
proposal
Current
policy
What
3-visit limit on
unnecessary
use
No-payment
for
unnecessary
visits
Adoption of
best practices
Impact
Cuts payments to
providers
Status
Won lawsuit;
policy abandoned
Cuts payment to
providers
Delayed by the
Governor just
prior to
implementation
Passed in latest
state budget
Improves care
delivery and
reliance on ER as
source of care
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Voices Heard
• Contact with legislators
• Contact with media
• Discussion of legal barriers
15
Savings without Penalties
Provides the state with savings by
asking hospitals, and their
physician partners, to implement
the right systems for care
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If Unsuccessful
Revert to the
no-payment policy.
$38 million in
annual cuts!
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Ultimate Goal: Reduce Trend
Current projected trend
Changing the trend
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Partners Will Be There
• Emergency room physicians will be pushing
for hospital adoption
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The Seven Best Practices
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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
21
How to Accomplish
Emergency Department Information Exchange (EDIE)
• 30 hospitals in Washington already using
• EDIE can:
– Notify ED physician of frequency of ED visits and summary
of ED discharges for past 12 months
– Share guidelines for patient with other hospitals
– Load patient’s treatment plan, so ED physicians can view
• Costs:
– Depends on number of ED visits
– $2,000 to $5,000 setup plus $1,200 to $30,000 a year
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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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How to Accomplish
• Use WSHA brochures or customize for your hospital
• Decide when and how to distribute
– Upon arrival, at discharge, or display prominently
• Incorporate into electronic discharge instructions, if
warranted
• Train ED physicians on educating patients about the
appropriate care setting
– Presentation disseminated by ACEP
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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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How to Accomplish
• Identify who at hospital receives and
disseminates information on PRC clients
• Use information in EDIE to alert physicians
– Frequent user = someone who has used ER five or
more times in the past 12 months
• Make PRC care plans available to ER physicians
• Best success with case management in ER
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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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How to Accomplish
• Develop system to call
primary care providers
during and after PRC visit to
emergency room
• Develop system to relay
issues regarding access to
primary care to the HCA
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E) Narcotic Guidelines
Goal: Reduce drug-seeking and drug-dispensing
to frequent ER users
• Implement ACEP guidelines for prescribing and
monitoring of narcotics
• Direct patients to better resources
• Track data and follow-up with
providers who excessively
prescribe
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How to Accomplish
• Change hospital policy to conform with
ACEP guidelines:
–
–
–
–
Prohibit long-acting opioids and discourage injections
Screen patients for substance abuse
Refer patients suspected of Rx abuse to treatment
Other
• Train ER prescribers in narcotic guidelines
• Consider joining “oxy-free” movement
• When guidelines implemented, hospitals
have seen significant drop in visits
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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
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How to Accomplish
• WSMA and WA/ACEP encourage members to
sign up
• Educate and encourage medical staff to enroll
• Hospitals track enrollment of ER prescribers to
report to HCA by June 15 and December 31,
2012
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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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ED WORK GROUP
WSHA, WSMA, WA/ACEP and the state Health Care
Authority will develop and monitor metrics on
performance by hospital and by physician
– Example measures:
•
•
•
•
Rate of unnecessary visits
Rate of visits by PRC clients
Rate of PRC clients with treatment plans
Rate of prescriptions with long-acting opioids
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How to Accomplish
• EDIE produces standard reports
• Hospitals may be called on to gather and
report other easily available data
• Feedback reports will be made public
35
Provider Training
• Hospitals must ensure providers
are trained
• WA/ACEP will provide template:
– Training providers on how to educate
patients on choosing the appropriate care setting
– Training providers on guidelines for narcotic
prescribing and monitoring
36
Quality Assurance
Each practice concludes:
“Hospital has a system of quality
assurance and intervention and
can routinely identify, report,
and correct cases of provider
noncompliance with these best
practices.”
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Do Other Laws Still Apply?
•EMTALA
•Medical malpractice
•Prudent layperson preserved
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Quick Action Needed!
• Hospitals must submit attestations and best
practice checklists to HCA by June 15, 2012
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If Unsuccessful in Signing Up
If hospitals
representing at least
75% of Medicaid ER
visits do not sign up,
the state will revert
to the no-payment
policy.
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Best Practices Just First Step
• HCA will perform a preliminary fiscal analysis
by January 15, 2013
• Focus:
– Outlier hospitals with high rates of unnecessary
visits
– High ER visits by PRC clients
– Low rates of treatment plans for PRC clients
– High rates of opiate prescriptions
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If Unsuccessful in Changing Trend
Actual trend
Projection
If the trend does
not go down, the
state could revert
to the no-payment
policy.
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Attestation Mailed to You
• Complete entire
form
• Send to HCA
• Send to WSHA
• We will follow up!
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Ongoing Oversight:
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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Next Steps
How We Will Help
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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!
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For More Information
Carol Wagner, Senior VP, Patient Safety
(206) 577-1831, carolw@wsha.org
Claudia Sanders, Senior VP, Policy Development
(206) 216-2508, claudias@wsha.org
Barbara Gorham, Policy Director, Access
(206) 216-2512, barbarag@wsha.org
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For More Information
Pauline Proulx
www.washingtonacep.org
Tim Layton
tim@wsma.org
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Questions and Comments
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