1. Reducing Preventable Emergency Room Visits June 15, 2012
I am pleased to be here today to talk about the ER is for Emergencies Campaign to reduce preventable emergency room visits.
Reducing Preventable Emergency Room Visits June 15, 2012

2. WSHA Presenters Carol Wagner Amber Theel Senior VP, Patient Safety
Director,
Patient Safety
Intro
Carol,
Amber

3. Presenters
Brigitte Folz, ACSW, LICSW, Interim Director Psychiatry and Behavioral Health
Ann Allen, Lead
High Utilizer Case Manger
Harborview Medical Center
Introductions
Harborview Medical Center 2

4. 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.
By June 15, 2012 hospitals must have implemented best practices on:
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

5. Partnering for Change Washington State Hospital Association
Washington State Medical Association
Washington Chapter of the American College of Emergency Physicians
This work has been led by a strong partnership between three organizations:
Washington State Hospital Association
Washington State Medical Association
Washington Chapter of the American College of Emergency Physicians

6. Emergency Room Overuse: It Is a Problem
Emergency room overuse is indeed a problem. The state is concerned about it for budgetary reasons.
But hospitals and physicians are also concerned because we want to be sure people are getting the care they need in the appropriate setting. We know the ER is not the appropriate setting for non-emergent care.

7. 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
It is true that Medicaid ER use is high. While some of the use of the ER is necessary, some of it is for care that should be delivered in another setting.
In the past year, about 40% of Medicaid clients visited an ER, compared to 18% of people with private insurance who visited an ER.
Some contributing factors for why people on Medicaid rely more heavily on the ER:
Lack of primary care
Substance abuse problems
Mental health issues

9. 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

10. Barriers Poor historian High anxiety
Lack of resources (housing, medication etc.)
High incidence of substance abuse

11. High Utilizer Case Management Program
WSHA Webcast – June 2012

12. 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.

13. 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 in ED and in the community
Networking with agencies to provide continuity of care
Respectful and compassionate care
Close team communication and supports
Relationship building in the field
Shelters, parks, freeway ramps, agency waiting rooms, fast food restaurants, buses
Client self determination and care planning
Network care conferences
Concrete resource provision – food vouchers, bus tickets, etc.

14. 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

15. 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

16. Case Study #1 ~50 y. o. man Aggressive networking of supports Homeless
Key network linkages:
Chemical dependency – primarily alcohol
Reach
Seattle Indian Health Board
Increasing medical problems with multiple ED visits for cellulitis and withdrawal seizures
DSHS - NA outreach worker
Chemical Dependency Involuntary Treatment Services
Legal issues
Interventions:
KC Detox
Assertive outreach and engagement
Now sober, stable housing, reconnected to family and native community
Supported housing
Bus tickets

17. 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.

18. 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

19. 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

21. 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) ) 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_______

22. Life is Complicated Mental Health Criminal Justice Chemical Dependency
Medical Care
Funding
Criminal Justice
Chemical Dependency
Housing

23. Ed visit data per patient: Year 1
Many patients had no ED visits after case management.

24. Pre- and post-services comparison: ED charges

25. 2012 Results

26. Reduction in ed and inpatient visits

27. 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 .

28. Program contacts
Brigitte Folz, LICSW (206) Ann M. Allen, LICSW (206)

29. What are the three top priority strategies that hospitals could use to make the biggest impact now?
Ask Brigitte to describe her top 3 priorities or interventions

30. 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.

31. 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
Adoption of the best practices is just a first step.
The Health Care Authority will perform a preliminary fiscal analysis by January 15, 2013 and report outcomes to the legislature.
Again, they want to see savings and a change in the trend of use of the ER for Medicaid patients.

32. If Unsuccessful
Revert to the no-payment policy. $38 million in annual cuts!
If we do not succeed in getting the attestations turned in and in reducing the trend of unnecessary emergency room visits, the consequences are clear. The state will revert to the no-payment policy for any ER visit it considers unnecessary. This means $38 million in annual cuts to hospitals and physicians!

33. 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
All three partners will be working together to ensure the success of this effort.
WSMA, The Washington State ACEP, and WSHA will all be at the table with the Health Care Authority as this process moves forward. The group will develop and monitor metrics on performance by hospital and by physician.
The three organizations will continue to advocate on your behalf and on the behalf of our patients.

34. Questions and Comments