The ED in Population Health

Utilization and Communication

Hans Notenboom, MD

Medical Director, Sacred Heart Emergency Departments

I have no relevant financial disclosures

Roadmap

History

Recommendations

Current tools

Examples

History

New England Healthcare Institute (NEHI) produces “Waste and Inefficiency in the Healthcare System” Examines areas of waste Suggestions for improvement Launched initiative to improve waste

The Triple Aim

Institute for Healthcare Improvement (IHI)

Improving the patient experience of care (quality and satisfaction)

Improving the health of populations

Reducing the per capita cost of health care

Much of this directly relates to the NEHI study

NEHI Study

30% of cost, or $700 billion in wasted care Care that could be eliminated without reduction in quality

Six major sources Unexplained variation in clinical care

Patient medication adherence Misuse of drugs and treatments Emergency Department overuse ($38 Billion) Underuse of appropriate medications Overuse of antibiotics

ED Use Rising

Many papers support this, as well as our collective experience Past 15 years has almost doubled at our facility 2000 – 50,000 visits per year

2015 – 90,000 visits per year

Why? Is that good or bad? What are the impacts?

Who and Why?

“Superusers” are 1% of ED patients but can account for 30% of costs

Insured actually responsible for much of the overuse

Limited access to primary care – huge issue locally

Convenience – after hours and weekends

Immediate reassurance of medical conditions

Primary care refers to ED

Hospitals have financial and legal obligations to treat all patients

Best Option for Care?

Fragmented care in ED Lacks benefit of continuity of care Over ½ of Americans have a chronic condition

Disease prevention

Follow through of treatment plans

Lack of care coordination Difficult for patients to understand discharge and aftercare

NEHI Recommendations

Establish collaborative relationships between EDs, primary care, and community services

Understand the patient population

Reform payment for primary care services

Invest in Healthcare Information Technology (HIT)

Increase the primary care workforce

Redesigning primary care services

Current Tools

Emergency Department Information Exchange (EDIE)

Prescription Drug Monitoring Program

What is EDIE?

EDIE is a web-based application developed to help Emergency Departments (EDs) identify high-utilization and complex needs patients who frequently visit EDs for their care, and who would be better served in a different care setting.

EDIE is…

Collaborative framework for case management

Proactive notification In the moment Coordinate on site

Bird in the hand

Way to share between different organizations or groups (i.e. ED doctors, social services, primary care), regardless of IT platform

EDIE isn’t…

Punitive or way to catch people

Full EMR

Full health information exchange (HIE)

EDIE Success: Washington

As part of the “ ER is for Emergencies” initiative to reduce unnecessary ED visits by Medicaid patients, EDIE

was implemented in 91 hospitals in Washington State.

11% State-wide Visit Reduction in Medicaid patients with 5 or more annual ED visits

58% Visit Reduction in patients with Care Guidelines

$33 Million in Savings for Washington State

EDIE in Oregon is growing

Summer of 2014, more than 62% of hospitals active and sharing information

All hospitals in Oregon signed attestations with plans to be live by the end of 2014.

Some Oregon details

Oregon tracking the ED visits, high utilizers and 60 day patients High utilizer is any patient that visits any ED 5 or more

times in a 12 month period 60 day patients include anyone that visits 3 or more

different EDs in a 60 day period

Information is sent to Oregon leaders and hospital leaders monthly

Breaks down by age, diagnosis and more

Most Recent Snapshot

Regional Breakdowns

Example of Diagnosis Breakdown

Age Breakdown

Results starting to show in Oregon

Some local specifics

Specific criteria can be set for each institution (# of visits, etc.)

Results available within 3-5 minutes of registration

Pushed to ED as well as care management (can be tailored)

Our criteria: 4 or more visits to the ED within 60 days 3 or more visits to any EDIE facility in 60 days

Care Planners – What Do They Do?

Find/verify PCPs and other providers, counselors, etc.

Notifications letters to PCP, providers

Enter plans of care and expectations

Link pain/medication contracts from outside sources

Education for proper use of ED / urgent care / PCP

Referrals for SDS, Medicaid, APS and community health workers

Coordinate in home health, transportation, hospice, equipment (O2)

Reminders for high risks (meds / conditions / behaviors / etc)

Assistance for coordination for people with no resources or ability (e.g. homeless with no phone)

Local Success

59 yo woman

History of ICH, multiple pain related complaints, seizures, and more

19 visits in 2014

EDIE flagged and care management addressed

Coordinated with VA, connected with care mgmt, and PCP

No visits since December

Local Success

57 yo male

Poorly controlled DM, medication non-compliance, pain, and mental health issues with depression and SI

24 visits in 2014 with multiple admissions

Homeless and living in a tent

Care planned and received medical respite care and coordination

1 visit since November 14

Local Success

Quicker identification

45 yo male with ETOH abuse and multiple hospitalizations

7 ED visits in 2 months with a few inpatient stays

Care planning set up with foster home, with parental coordination.

No visits in past 3 months since care coordination

Future Opportunities

Closer coordination with urgent cares and PCPs to get the right patients, the right treatment, at the right times

Shared protocols through information exchange (e.g. EDIE) to impact outcomes and utilization Reduce variability and stop the ‘shopping for treatment’

Telemedicine Augmented ‘ask-a-nurse’

Reassurance and triage coordination

Further advancements of technology Broader Health Information Exchange (HIE)

Questions??