2011 Study of Emergency Services Utilization in the Capital Region of NY Kevin Jobin-Davis, PhD R 5 Initiative — Improving Access to the Right Care in the Right Place at the Right Time for the Right Reason at the Right Cost

HCDI Members County Health DepartmentsHealth Plans Albany County Department of HealthCapital District Physicians’ Health Plan Rensselaer County Department of Health Fidelis Care New York Schenectady County Public Health Services Senior Whole Health Hospitals Federally Qualified Health Centers Ellis Hospital Hometown Health Services Albany Medical CenterWhitney M. Young, Jr. Health Services Seton Health/St. Mary’s Hospital St. Peter’s Health Care Services Northeast Health/Samaritan Hospital/Albany Memorial Hospital Community Partners Catholic Charities of the Catholic Diocese of Albany Healthy Capital District Initiative |

HCDI – Improving Access to Health Services Public Health Insurance  Free application assistance for Medicaid, CHP, FHP – 4,200 people served annually  Community Health Advocates - information and assistance accessing health insurance and health services Seal A Smile School-based Dental Services  Preventative oral health services – 3,250 served annually Poverello Center  Primary Care for Uninsured Adults – 350 served annually Healthy Capital District Initiative |

Public Health Planning  Analyze available State & Local Health Data  Collect and Analyze local data  Support County and Hospital health planning requirements – CHA and CSP  Develop local and regional initiatives to address targeted health needs Healthy Capital District Initiative |

Target Population: Sub-optimal ER Users Suboptimal ED Use  Non-emergent  Frequent flyers  Preventable and chronic illness Individual Forces  Pain  Knowledge of health resources  Work conflicts  Transportation  Social support Health System Forces  Primary care availability  Referral policies  Support services  Intake/discharge policies  Inter-organization communication The R 5 Initiative Improving Access to the Right Care in the Right Place at the Right Time for the Right reason at the Right Cost Healthy Capital District Initiative |

6 R 5 Goals Identify causes of sub-optimal ED use Identify promising practices and facilitate wider adoption in the Capital Region Improve patient & provider engagement with primary, preventive, and managed care through collaborative interventions, resulting in better health outcomes Collaboratively develop protocols to improve patient flow through the health system

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2008 Capital District Emergency Department Visits Healthy Capital District Initiative | 8

9 Top 10 Non-Emergent Diagnoses

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13 Healthy Capital District Initiative | Consumer Survey HCDI developed a voluntary, anonymous consumer survey to be distributed in local EDs to determine the key factors that affect a person's decision to choose an ED for health care 575 surveys were collected from Albany Memorial, Ellis, Samaritan, Albany Medical Center and St. Peter’s Surveys contain a combination of open-ended and multiple choice questions on Likert scale

14 Healthy Capital District Initiative | Results Reporting Open Ended Questions Top Reason and Top 3 Health Condition vs. Provider Characteristics Why this Particular Emergency Department Closed Ended Questions 5 point Likert Scale Strongly Disagree to Strongly Agree

15 Healthy Capital District Initiative | Consumer Themes for Selecting Emergency Care Table I: Top Reason Patients Chose ED for Care Theme% RespondentsResponses Health Condition Characteristics50%287 Convenience17%97 Provider Service Quality15%84 Doctor Referral9%50 Other10%57 Table II: Top 3 Reasons Patient Chose ED for Care Theme% RespondentsResponses Health Condition Characteristics100%575 Convenience53%304 Provider Service Quality45%260 Doctor Referral14%81 Other29%165

16 Healthy Capital District Initiative | More Specific Factors for Selecting Emergency Care Table III: Health Condition Factors in Top 3 ED Use Reasons Factor% RespondentsResponses Symptoms53%305 Pain34%197 Severity / Urgency11%62 Unintentional Injuries3%15 Provider Related Factors in Top 3 ED Use Reasons Factor% RespondentsResponses Quality of Care40%231 Proximity21%122 Quickness17%100 Hours of Operation14%82 Medical Referral12%67

17 Healthy Capital District Initiative | Factors in Selection of Particular Hospital’s Emergency Services Table IV: Primary Reasons Patients Selected Particular ED by Theme Theme% RespondentsResponses Convenience52%277 Provider Service Quality39%206 Prior Visits26%139 Doctor Referral5%29 Stated No4%20 Health Condition Characteristics4%19 Other14%77

18 Healthy Capital District Initiative | Consumer Defined Rationale for Choosing Emergency Services Overall, symptoms and convenience are the driving factors for people to seek care Pain and the quality of care are important secondary considerations Selection of particular emergency service providers, is similarly influenced by convenience, then service quality factors, with prior visit experience also a consideration

19 Healthy Capital District Initiative | Most Commonly Shared Reasons for Seeking Emergency Services

20 Healthy Capital District Initiative | Phone Triage and Access Issues

21 Healthy Capital District Initiative | Consideration of Urgent Care, Primary Care, and Emergent Care

The Convenience of Accessing Emergency Care Healthy Capital District Initiative | 22

The Inconvenience of Accessing Primary Care Healthy Capital District Initiative | 23

24 Healthy Capital District Initiative | Summary of Patient Reasons for Selecting Emergency Health Services The sense of urgency (84%) and pain (76%) associated with the trauma is the primary motivation for seeking emergency services The convenience of comprehensive, timely services regardless of insurance are the major draws for patients Patients don’t distinguish clearly emergent from primary care treatable conditions (42% of ED visits) The vast majority (80%) do not consider the ED a better source of care than primary care Not establishing a primary care provider was a factor for 1 in 3 respondents

25 Healthy Capital District Initiative | Methods of Gap Analysis Discussion/Meetings – 35 different providers (e.g., primary care physicians, emergency department (ED) nurses, patient navigators, case managers, urgent care clinic nurses, medical directors, discharge planners, long-term care providers, and others Surveys – 13 primary care doctors – 3 hospitals – 4 nursing facilities – 3 urgent care centers

26 Healthy Capital District Initiative | Major Gaps Care management Patient handoff Capacity Protection from liability Alternatives to the ED

Primary Care Providers (PCP) Capacity and support for timely preventive care is lacking – Same day appointments at primary care offices limited Payment systems do not support robust primary care – No reimbursement for extra time managing care There are extra challenges for the publicly insured – Some PCPs don’t accept MA; wait before seeing PCP PCP shortages are acute for certain health conditions – Dental, mental health, and substance abuse were cited often Healthy Capital District Initiative | 27

Hospitals EDs are not geared to manage care – Focus is emergent care, not chronic care There are barriers to effective follow-up – Little time to educate patient; limited record exchange Healthy Capital District Initiative | 28

Hospital / PCP Care Coordination Findings EDs communicate with affiliated physicians EDs communicate with PCP re: admissions FQHCs typically must actively seek info Other instances, follow-up left to patient Healthy Capital District Initiative | 29

Long Term Care / EMS Senior housing can’t manage residents’ health or provide services Many home and community-based providers fear liability if they don’t send patients to the ED If called, EMS must take patients to the ED Healthy Capital District Initiative | 30

Urgent Care Centers (UCCs) and Federally Qualified Health Centers (FQHCs) There is not widespread awareness about UCCs or FQHCs as an alternative to the ED UCCs not located in urban areas Certain diagnostics only available at ED Service hours are limited Healthy Capital District Initiative | 31

What to Do? Improve Access to Primary and Preventive Care Help Consumers Distinguish Primary Care Treatable Conditions from Emergent Bolster Communication between Emergency Departments and PCPs Healthy Capital District Initiative | 32

ACCESS TO PRIMARY AND PREVENTIVE CARE Facilitated Enrollment education on importance of primary care/well visit and assistance with securing PCP Development of evening primary care services in urban centers

CONSUMER SELECTION OF HEALTH SERVICES Develop messaging and materials on benefits of primary care to support referrals of ED patients without a PCP Targeted outreach in areas with high self-pay population Develop marketing campaign on the benefits of Primary Care

COMMUNICATION BETWEEN EMERGENCY DEPARTMENTS AND OTHER PROVIDERS Launch pilot exchange of ED visit information with primary care group Enhance referral processes of ED patients without a PCP to primary care

Contact Healthy Capital District Initiative 315 Sheridan Ave. Albany, NY Kevin Jobin-Davis (518) Healthy Capital District Initiative |