florida emergency department collaborative results of ed utilization analysis and initiatives...
TRANSCRIPT
Florida Emergency Department Collaborative
Results of ED Utilization Analysis and Initiatives Questionnaire
June 8, 2011
Presented by:Howard Pitluk, MD, MPH, FACS, Vice President/Chief Medical OfficerMargaret deHesse, RN, BSN, Executive Director State and Corporate Services
Plans Who Provided Data
HMO PSN
Humana, Inc. Sunshine State Health Plan
Medica Health Plans of Florida First Coast Advantage
Better Health, LLC South Florida Community Care Network
Molina Healthcare of Florida Children’s Medical Services Network Duval
Freedom Health (Freedom 1st) Children’s Medical Services Network Broward
UnitedHealthcare Community Plan
Universal Health Care
ED Utilization Analysis
11 out of 12 plans conducted an Emergency Department utilization
analysis
When was the Analysis Completed?
73
11
2011 2010 2009 Never
Did the analysis include identification of visits to the ED that could have been
treated by the PCP?
6
5
Yes
No
None of the plans used the New York University (NYU) Algorithm for the ED analysis
Medica - HMO Universal Sunshine - HMO South Florida - PSN CMS Duval - PSN
URI X X X X
Viral Syndrome X X
Sore Throat X
Croup/Cough X X X
Otitis Media X X X
Gastroenteritis X X
Asthma X X
Low Back Pain X
Dental X X X
Fever X X X
Pharyngitis X X
Abdominal Pain X X
UTI X X
Vomiting X X
Ear Pain X
Rash X
Conjunctivitis X
Constipation X
Allergic Rhinitis X
Insect Bite X
Top Conditions of Avoidable ED Visits
Observations of ED Analysis by HMOs/PSNs
A small percentage of members account for a high
percentage of ED use (ultra utilizers)
Majority of visits for members < 21 years of age
Majority of visits for members 0-5 years of age
Did the Analysis Identify Ultra Utilizers?
8
3
Yes No
Conditions of the Ultra Utilizers
Each of the following conditions was identified as a Top Ten Condition of Ultra Utilizers by just one plan:
Sickle Cell Disease Behavioral Health Issues
Abdominal Pain Gastroenteritis/Colitis
URI Otitis Media Fever Diarrhea
Chest Pain Obstetrical Orthopedic Toothache
Diabetes Spinal Stenosis Digestive Viral Infection
Rash Sore Throat Bronchitis Headache
Head Injury UTI Symptoms , Signs, and Ill defined conditions
Diseases of the Nervous System and Sense Organs
Each of the following was identified once by the plans as a Top Ten diagnoses of the Ultra Utilizers
Member Education and Outreach –
Welcome packets - Location of urgent care centers
Use of 24/7 nurse line
Reminder letter to schedule appointment with PCP
Educational materials on ED use
Encourage linkage to PCP
Assist member with changing PCPs
Current Initiatives
Case Manager/Health Coach -
High utilizers – Refer to case/disease management
Assist members with scheduling PCP appointments
Behavioral health co-management
Health coach – Real time follow-up
Provider Education and Outreach –
Educate providers about urgent care options
Notification of member ED use
Notification of high opiate use
Current Initiatives
Emergency Department
Daily/ Weekly ED Census
Work with ED Staff to conduct a face-to-face meeting
with member and perform an ED assessment
Current Initiatives
Sunshine State –
90 percent of members stopped going to the ER
10 percent still use multiple times
Greater than 40 percent decrease in ER usage overall
Universal - Results showed a decrease in ED usage for the pilot
county
Current Initiatives - Evaluation
Humana -
Pre-evaluation ED usage of the entire population - 5.5
Post evaluation usage - 4.9
Pre-evaluation of members who had interventions - 7.4
Post intervention - 2.3
Current Initiatives - Evaluation
Series10
1
2
3
4
5
6
5
6
Yes No
Daily Census from EDs
Methods of Receiving Census
Type Name MethodHMO Sunshine State Fax
HMO Humana N/A
HMO Medica N/A
HMO UnitedHealthcare Fax
HMO Freedom Health-Freedom 1st N/A
HMO Molina Healthcare N/APSN Better Health LLC Method unknownPSN CMSN Broward Self-run reportPSN CMS Duval N/APSN First Coast Advantage Hospitals email and fax daily ED censusPSN South Florida Community Care Self-run report
24/7 Nurse Advice Line
Series10
1
2
3
4
5
6
7
5
7
Have a Nurse Line Do Not Have a Nurse Line
Health Plans
• 4 HMO/PSNs have a 24/7 Nurse Advice Line for members
Nurse Advice Line Usage
Type Plan UsageHMO Sunshine State Less than 1%
HMO Humana Not sure of exact percentage but it is probably low
HMO Medica N/A
HMO UnitedHealthcare No response
HMO Freedom Health-Freedom 1st N/A
HMO Molina Healthcare Less than 5%
HMO Universal No response
PSN Better Health LLC No response
PSN CMSN Broward N/A
PSN CMSN Duval 1% (Behavioral Health only)
PSN First Coast Advantage N/A
PSN South Florida Community Care N/A
Care from Non-PAR Providers
Type Plan ResponseHMO Sunshine State HP Less than 1%
HMO Humana Not known but probably low
HMO Medica 6.1% (285 members)
HMO UnitedHealthcare Unknown
HMO Freedom Health-Freedom 1st Unknown
HMO Molina Healthcare Less than 5%
HMO Universal Unknown
PSN Better Health LLC Minority of members
PSN CMSN Broward 20%
PSN CMSN Duval 7.90%
PSN South Florida Community Care 20%
PSN First Coast Advantage 32.7 %
Member -
Need member education on treating minor ailments
Real time outreach is effective
High illiteracy rate - welcome packets of little benefit
ED -
Lack of communication between EDs
EDs advertise low wait time
Considerations for the ED Collaborative
21
Other
Use mobile diagnostic units for preventive services
High volume of ED use at non-contracted facilities
No link between mental health vendor and MCP
regarding ED use driven by mental, alcohol and substance
abuse disorders
Underlying diagnoses in children often make ED visits
the correct choice
Considerations for the ED Collaborative
22
Series10
0.5
1
1.5
2
2.5
3
3.5
44 4 4
Tracked by HMO/PSN Tracked by Vendor
How are members with Behavioral Health conditions who access the ED tracked?
Behavioral Health
23
A Look at Ohio’s Statewide ED Collaborative
24
Structure
Statewide Collaborative (IMPROVE)
Five Regional Steering Committees
Patient Streams
Ultra Utilizers: Mental Health, Non-mental Health,
Chronic Back Pain
Dental
URI - Statewide
Overview
25
High utilizers are identified as sample members.
Interdisciplinary Teams develop care treatment plans to establish a coordinated care approach. The goal is to meet the sample members’ needs and re-direct them to their medical home rather than the ED.
Sample members are flagged at participating EDs.
If a member in the sample accesses the ED, the attending ED Physician will:
Reference the care plan summary, and
Notify the Interdisciplinary Team contact person that a sample member has accessed the ED.
The Interdisciplinary Team continually outreaches sample members and coordinates care to reduce avoidable ED visits.
Ultra Utilizers Intervention
Buckeye(5 Sample Patients)
Case Managers
Care Source (5 Sample Patients)
Case Managers
Unison (3 Sample Patients)
Case Managers
Mercy St. Vincent [ED]
Toledo Hospital [ED]
University of Toledo [ED]
NORTHWEST REGION – BACK PAIN
TEST SITES TOTAL PATIENTS IN TEST INTERVENTION = 13
MercySt VincentPain Clinic
Care Treatment Plan
Emergency Departments
Contact: Clinic Manager
26
Integrated Care TeamManaged Care Plans
(MCPs)
27
Business Hours Medicaid managed care members presenting with dental conditions
are identified at the ED.
EDs call participating dental providers and secure a fast-tracked dental appointment for the patient.
EDs forward the identifying information of sample patients to the appropriate MCP.
MCPs follow-up with the member.
After-Hours ED staff distribute a card listing the MCP contact information and
instruct the patient to call the MCP during business hours for a fast-tracked dental appointment.
Dental Intervention
28
1. Sample members receive a kit for colds which promotes the managed care plans’ (MCP) 24-Hour Nurse Advice Line with a “call early, call often” theme Most sample patients receive the kits through the mail with a letter from their
primary care physician (PCP) or their health plans’ medical director. In the real-time test interventions, kits are distributed at the ED.
2. MCP Nurse Advice Lines triage sample members and bridge services the MCP has to offer with follow-up PCP care
3. PCP office provides next day/same day appointment scheduling for sample members
4. An MCP Health Coach follows-up with members in the test intervention sample
URI Intervention
29
Questions