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

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

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

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

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

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.

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

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

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

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 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.

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 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

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 Mental Health Criminal Justice Chemical Dependency Medical Care Funding Criminal Justice Chemical Dependency Housing

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

Pre- and post-services comparison: ED charges

2012 Results

Reduction in ed and inpatient visits

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 .

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? Ask Brigitte to describe her top 3 priorities or interventions

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.

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.

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!

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.

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