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Pediatric Emergency Department (ED) Case Management

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Presentation on theme: "Pediatric Emergency Department (ED) Case Management"— Presentation transcript:

1 Pediatric Emergency Department (ED) Case Management
Ramona Waltman, RN, BSN, CCM Children’s Healthcare of Atlanta 1

2 Why do patients use the ED?

3 Children’s Healthcare of Atlanta Who Are We?
3 Hospitals 529 Beds 24, 572 admissions for 136,769 bed days 778,881 visits for 326,182 patients 17 Neighborhood Locations 5 Urgent Care Centers Marcus Autism Center 1 Primary Care Office Children’s Healthcare of Atlanta Who Are We?

4 Facts and Figures 200,000 yearly Emergency Department visits = 550 a day 100,843 Urgent Care Visits 46,551 Primary Care Physician Visits Serviced all Georgia counties, 43 states and countries around the world

5 Children’s Healthcare of Atlanta is the:
One of largest Clinical Pediatric Provider in United States Largest Georgia Medicaid Provider 10th private employer in Georgia with 7800 staff Trauma Provider for pediatrics in Georgia Pediatric Rehabilitation Services Transplant Services AFLAC (Hematology/Oncology Services) Focus on Disease Management, Asthma and Diabetes

6 Transplantation Performed at Children’s Healthcare of Atlanta
Liver, Kidney, Bone Marrow and Hearts 475 Kidneys 19 Livers, youngest and smallest patient weighing 2 pounds Only pediatric center in Georgia for heart transplants, performed 3 transplants in a 24 hour period, one of few centers for ABO incompatible blood types 62 Bone Marrow Transplants and cures for 30 patients with Sickle Cell Disease

7 Strong 4 Life Program Addressing childhood obesity jointly through efforts and partnering with community support and government agencies in Georgia 40% of Georgia’s children are obese, making Georgia 2nd in the country for obesity in children Children’s Healthcare of Atlanta employees have lost 35,459 pounds with fitness opportunities

8 Why Children’s Healthcare of Atlanta is Crucial to Georgia
28% of Georgia’s total population are children 52% of those children are enrolled in Medicaid or Georgia’s State Children’s Health Insurance Program (SCHIP) known as Peach Care 300,000 of Georgia’s children are uninsured Children’s Healthcare of Atlanta provided $90 million in unreimbursed care in 2011

9 Where to go?

10 Georgia Medicaid Traditional Medicaid manages children who are eligible for supplemental security disability income and children in foster care The remainder of children enrolled in Georgia’s Medicaid program are enrolled in one of Medicaid’s care management organizations Wellcare Amerigroup Peachstate Another option is Peach Care, Georgia’s state child health insurance program. This option requires income eligibility and a monthly premium payment at a reduced rate for the families

11 Why use the Emergency Department instead of Primary Care Providers?
Convenience Decreased wait times – Victims of our Own Success Perception of Quality of Care ED access to diagnostic tests not available at Primary Care Provider Transportation barrier among families Often one car family (mother not driver) or a neighbor’s car available Financial Incentive Co-pays established for Primary Care Provider visits but not Emergency Department visits by Care Management Organization for Medicaid patients

12 Georgia Medicaid Traditional Medicaid manages catastrophic illnesses and children in foster care Remainder of Children are enrolled in Medicaid care management organizations Wellcare Amerigroup Peachstate Nominal fee for coverage through Peach Care, which is Georgia’s state child health insurance program

13 “I am not feeling well, I vomiked twice!”
When can I see you?

14 Patient Barriers to Primary Care Access
Perceived barriers when contacting Primary Care Providers (PCP) Access to PCPs’ nurse advice line “If you feel you have an emergency hang up and call 911 or go to the nearest ED” “ If you want to talk to a nurse or physician, this call will be subject to a $15 charge. Any calls to the CHOA nurse advice line will also be subject to a $15 charge. (Call center Services must charge fees due to Stark Laws while most insurance companies have a 24hr free nurse advice line) 1 Limited availability “same day” and “after hours” appointments Compensation model from payers 1 Zaman Pediatrics After Hours Line

15 Pediatric ED Case Manager Position and Scope of Work
SR Case Manager position started Jan 1, 2012 1 FTE Staffed 8am-5pm 5 days/week (rotates between 2 main campuses) 2500 ED CM referrals in the first 6 months

16 Pediatrics ED Case Manager Key Objectives
Identify and reduce patient access barriers that result in non- emergent ED visits Target subset “high utilizers” Work directly with 3 Medicaid care management organizations (CMO) ED Case Managers to address payer specific barriers to primary care Support ED physicians to ensure adequate follow up for primary and specialty care Coordinate referrals to Patient Financial Services to determine financial eligibility for Medicaid Partner with ED physician and nursing staff to identify risk factors and patient specific conditions leading to 72hr ED returns Educate ED physicians on documentation of medically necessary admission criterias

17 Connecting Patients and Payers
3 Medicaid Care Management Organizations in Georgia Daily list of ED visits sent to payers Initiated communication with hospital and CMOs Identify any actionable barriers to care that result in ED visits? Identified contact individuals at each payer source Target frequent ED users (6 visits/rolling calendar year) Identify actionable items representing barriers to access resulting in repeated ED visits Primary Care Physician assignment Assigned to a specialist instead of Primary Care Physician Primary Care Physician assigned is great distance from home Transportation barriers among patients and caregivers Lack of access to free or low cost medical and dental clinics for uninsured pediatric patients Provide community clinic lists 17

18 Case Manager Identifies Barriers to Outpatient Follow-Up
Neurology services Reduction in physician providers on one campus from 7 to 4.5 Neurology practices are non-providers in Medicaid and CMO plans for outpatient visits Orthopedic services Resolved out of pocket expenditures for fracture patients covered by one CMO payer Identifying barriers to follow-up care for uninsured, Medicaid pending and non-documented citizens

19 Outpatient Follow-Up Barriers Finding a Solution
2 new seizure clinics operationalized Decreased time for new seizure follow up appointments from 2 months to 1 week Clinic physicians provides Neurology Services for hospitalized patients Partnered with Neuroscience Service Line First Time Non Febrile Seizure Pathway CM responsible for ED patient follow-up Referral s of patient to Seizure Clinic

20 Primary Care Collaboration
Initiated meeting with Medical Director and staff of Primary Care Established communication to identify Primary Care patients with high Emergency Department utilization Reported scheduling issues identified at Primary Care Identified Primary Care patients who could benefit from Primary Care follow-up post Emergency Department visits Reporting initiated to provide data for Primary Care patients treated in ED setting, being shared weekly to identify need for follow-up at Primary Care

21 Uninsured Patients Reducing the Financial Impact
Identified that uninsured patients (potentially eligible for assistance) receive limited follow up by our financial counseling team ED charges < $3,000/visit frequently routinely not recovered Problem identified by ED Case Manager Established a process to identify and refer patients to financial counseling Single ED visit > $3,000 6 emergency department visits in 12 month period Multiple siblings treated during same ED visit Out of state Medicaid patients who have moved to Georgia and need to transition/apply for Georgia Medicaid Currently tracking financial success with a goal of recouping 10% ED charges on patients eligible for coverage

22 Future Goals for Tracking
Are there trends of unscheduled ED return visits that can help identify high risk conditions and patients? Bronchiolitis Cellulitis Track unscheduled 72hr ED return visits categorized by Age of patient Payer source Diagnosis Reason for return to ED

23 Admission Level of Care: Getting it Right on the Front End
Increasing pressure to justify medical necessity for short inpatient admissions Insurance denials RAC Audits Significant difference in compensation between Inpatient vs. Observation Admissions Educate physicians on documentation of medical necessity criteria for DRGs with 1-2 days LOS Asthma Pneumonia Bronchiolitis Acute Gastroenteritis

24 Pediatric ED Case Manager Tracking Performance
Patients with high utilization of ED services referred to each CMO Document follow up from payer at 3 months Assess impact in reducing non-emergent ED visits Number of uninsured patients referred to financial counseling Reimbursement received through retroactive Medicaid billing Medical predictors by DRG for 72 ED return and subsequent readmission Bronchiolitis (age, 02 saturation) Cellulitis (age, presence of abscess, location infection, presence of fever)

25 Meeting The Case Management Need
Tracking patients who left without being seen Tracking patients who leave against medical advice Prevention of unnecessary ED visits Expanding the coverage to second campus

26 Summary of Patients Receiving Benefits of ED Case Management at Children’s Healthcare of Atlanta
Patients needing specialty care follow up: Neurology Orthopedics Patients needing a better fit with their primary care physician Patients covered by Care Management Organizations (CMO) who need coordination of care Patients who are uninsured/non-documented and require continuation of care Patients covered by out of state Medicaid programs who reside in Georgia and need to transition to Georgia Medicaid

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