1. Reducing Medical Costs and Improving Clinical Care, Coordination & Outcomes by Reducing Admissions for High Utilizers of Emergency Care Services Sara Tracy, MSPH Senior Manager, Emergency Services & South Hospital Operations, Kaiser Foundation Health Plan of Colorado Kevin Vanderveen, MD Colorado Permanente Medical Group Assistant Regional Department Chief, Emergency Services Physician Director, Telephone Medicine Center Joanne Whalen, PsyD Licensed Clinical Psychologist & Behavioral Medicine Specialist, Kaiser Permanente of Colorado Collaborative Family Healthcare Association 15 th Annual Conference October 10-12, 2013 Broomfield, Colorado U.S.A. Session #D5b Saturday, October 12, 2013

2. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

3. Objectives Identify one model of using integrated care teams to reduce emergency room admission rates and Recommendations for replication in other health care settings. Identify key players in a health care organization needed to implement such a program. Identify critical components for successful implementation of care conferences.

4. “High” utilizers w/ 6 or more visits in one year 2010 ED spend alone = $3.8 million Average visits = 8.7 per 12 months Average yearly spend per member:  Commercial: $16,500  Medicare: $8,200 7.8% connected w/ Chem Dep 35% connected w/ Mental Health Remaining 57% not connected w/ either

5. Type of patients Isolated medical issue that results in several ED visits and then resolves (ex: acute MI, trauma, surgical abdomen etc.) Chronic pain issues Misuse of controlled substances Other chemical dependency issues – i.e. alcohol dependency Behavioral health issues that manifest as physical complaints (i.e. anxiety leading to chest pain) Patients with challenging social issues & possible placement needs – may be becoming unable to care for self in current situation Patients with complex medical issues & emergency needs

6. Why intervene? Improve quality of life for patient and improve quality of care patient is receiving Improving coordination of care within integrated care system Reduce cost to patient and organization Partner w/ local ED’s to help them care for these patients Reduce unnecessary (& potentially harmful) diagnostic testing & treatment Provide support to Primary Care Physician & care teams for patient

7. Why Primary Care Interventions Everything mentioned on previous slide! Primary care in most cases has strongest relationship with patient Enhance and strengthen the “medical home”

8. How we identify ED high utilizing members Real time report from many local ED’s on admissions of KP patients – patients with 6 or more visits/year are flagged Local Emergency Depts will call KP and notify of frequency of ED visits and/or drug seeking behavior Local provider may notice frequency of ED visits

9. Once patient is identified, what do we do? Chart review to identify trends Convene all providers critical to patient’s care for care conference PCP Nursing team Behavioral Health/Chem Dependency Emergency Care Providers Clinical Pharmacist Social work/care coordination services Include outside providers as needed

10. Purpose of care conference, cont. Identify drivers of ED visits Identify any other support/outreach needed & who will do it Review medications if needed & make changes Identify interventions

11. Purpose of care conference Notify appropriate outside entities that a care plan is in place (i.e. emergency departments that patient visits) Establish plan going forward for future ED visits Determine next steps & any further follow up or review needed

12. Controlled Substance Issues & Solutions Ensure there is a written opioid agreement Explicitly stipulate that controlled substances MUST be obtained from a single source for chronic pain— verify with state controlled substance database Continued receipt of controlled substances tied to certain behaviors—i.e. regular follow-up with behavioral health, evaluation by chemical dependence 28 Day refills Provision for notification of other providers – i.e. dentists

13. Behavioral Health Reviewing EMR for relevant mental health history Outreaching patients to get connected to BH Educate & support medical staff on dealing with BH/CD patients Education & skill building for patients related to coping w/ pain & BH/CD issues

14. Barriers Financial – patient unable to afford cost of recommended treatment Patient willingness and/or ability to participate in recommended treatment plan Social and/or family issues Transportation

15. Challenges, roadblock, & obstacles Buy in from primary care Practice variation/lack of consistency Varying financial incentives in different care settings Documentation of care plan Perceived loss of physician autonomy Perceived liability issues Perceived patient satisfaction issues Lack of accountability & incentive

16. Critical Components to successful implementation Chart etiquette & standardized documentation of plan Key providers involved & invested in care conference Buy in from organization leadership External & internal communication Consistency in practice & willingness to follow through w/ plan

17. Success of the intervention Pre and post (12 months each) data from institution of the program in 2010 shows 55% reduction in ED costs and 40% reduction in visits. Several patients have completely detoxed off of narcotics completely Will not be able to impact all patients

18. 2011 Results

19. Case Example: Megan 19 year old Caucasian female college student Frequent ER visit for believed allergic reaction for prior 4 years (one required intubation) 50+ epi pen injections in the last 4 years # ER visits 12 months Pre-intervention Pre-intervention ER costs 12 months prior # ER visits 12 months Post intervention ER Costs 12 months Post intervention 8$19,9121$974

20. Megan – Intervention Allergist recommended test to take in the ER to confirm (dispute) reaction Confirmation that not having reaction allowed room to work on anxiety Brief CBT treatment with Behavioral Medicine Specialist (exposure with response prevention, relaxation exercises, challenging irrational thoughts) Significant improvement in quality of life

21. Case Example - Susan 48 y/o disabled Caucasian female Frequent ED & clinic visits over 10 years for migraine headaches – treated with IM cocktail including narcotics # ER visits 12 months Pre-intervention Pre-intervention ER costs 12 months prior # ER visits 12 months Post intervention ER Costs 12 months Post intervention 29$11,8794$2,526

22. Susan - Intervention Departure of previous PCP opened the door for new treatment plan Discussed with patient weaning her off of narcotics Initial reaction in first six weeks from patient was anger at providers Two months post intervention, patient reported only “mild” headaches and had not been back to ED

23. Case Example - Amy 54 year old female office employee Known CAD, multiple visits to the ED over the years for chest pain Co-morbidities of anxiety disorder, breast CA # ER visits 12 months Pre-intervention Pre-intervention ER costs 12 months prior # ER visits 12 months Post intervention ER Costs 12 months Post intervention 20$48,4316$13,840

24. Amy - intervention Care conference included cardiology team who saw Amy often in the office Added Rx for anxiety when Amy experiences chest pain Connection with behavioral health provider and teaching re: mindful eating, stress reduction, anxiety management Patient able to wean off of home oxygen soon after intervention after two years on oxygen

25. Learning Assessment Audience Question & Answer

26. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!