CMs educate members on appropriate ED use

Program targets frequent flyers

Faced with rising costs for emergency department visits among its members, Physicians Health Plan of Mid-Michigan's FamilyCare Medicaid program launched an emergency room case management pilot program to help control inappropriate emergency department use.

"As we looked at our financials, we could see emergency department costs continuing to go up. We looked at solutions to the problem and decided to try performing case management in the emergency department," says Mary Anne Sesti, RN, MMA, director of government programs for the Lansing-based health plan.

The initiative was nominated for a Pinnacle Award given by the Michigan Association for Health Plan for innovations in quality care. But when the Medicaid membership declined, the health plan discontinued the program for budgetary reasons.

Using EDs appropriately

"We felt that the pilot program was very successful. The need is there to educate people on how to navigate the health care system, how to use the emergency department appropriately, and what community services are available," Sesti says.

Individuals who are covered by Medicaid use the emergency department inappropriately for many reasons, Sesti points out. Although all members in the Family Care program are assigned to a primary care provider, many continued to use the emergency department for primary care.

"The members all had been assigned a primary care physician but they were not necessarily established with the physician. Many of these members don't understand the concept of having a primary care provider. Others have transportation problems," Sesti says.

It may take six weeks for members to get an establishing appointment with their primary care physician. When they are sick, they often just come to the emergency department, she says.

The Medicaid population is transient and often is hard to locate, she adds. In some cases, the members never had received the introductory member packet that assigned them a primary care physician. Other emergency department "frequent flyers" visit the emergency department in search of drugs for chronic pain or have other chronic conditions that are not under control, such as diabetes or congestive heart failure, she adds.

Since Physician's Health Plan of Mid-Michigan is an affiliate of Sparrow Health System, Sparrow Hospital, a 600-bed hospital located near the health plan's offices, was the logical place to assign case managers.

Sesti and her staff worked with the hospital administration to create the case management program and to define how it would work. "We had to engage the emergency department director and the staff, as well as coordinating it within our own care coordination department," she says.

The health plan initially assigned one nurse case manager to the hospital in July 2006. Her efforts were so successful that a second nurse was assigned in November 2006.

The health plan case managers covered the emergency department from 9 a.m. to 9 p.m. weekdays and rotated working on weekends.

Sparrow Hospital already had discharge planners assigned to the emergency department who helped integrate the case managers from the health plan into the flow of the emergency department. "They were very helpful to our case managers who, in turn, helped them handle the influx of patients," Sesti says.

Initially, the emergency department staff notified the health plan case managers when a member came into the emergency department. Eventually, the case managers were able to access the electronic emergency department census throughout the day to locate the members they needed to see.

As part of the arrangement with the hospital, the case managers waited to see the patients until a physician had completed the assessment required under the Emergency Medical Treatment and Active Labor Act (EMTALA).

"We focused on the people who did not have medical emergencies. If they were clinically ill enough to be admitted, we didn't intervene," says Melissa Medlock, RN, BSN, one of the emergency room case managers.

The case managers talked with the members about reasons for their visit and educated them on appropriate use of the emergency department.

"We educated them about the benefits of seeing a primary care physician and facilitated getting an appointment for them. If it was a matter of not having transportation to get to the doctor's appointment, we referred them to the health plan's transportation coordinator for assistance," Medlock says.

The case managers educated the patients about signs and symptoms to report, when to come to the emergency department, when to call their primary care physician, and how to use the health plan's services.

Based on the members' situation, the case managers referred them to any community resources they might need as well as resources available to them through the health plan.

The case managers referred appropriate patients for care coordination or to disease management programs. For instance, some patients who have low back pain came to the emergency department frequently to ask for drugs. The case managers referred them to the health plan's low back pain disease management program.

If children came in with asthma, the case manager made sure they had an asthma action plan and referred them to the health plan's asthma disease management program.

If the members needed follow-up, the case managers referred them to the care coordination department for case management.

Each morning, the case managers got a list of members who presented at the emergency department but left without treatment. They called the members to find out what the situation was and to get them the help they needed.

"The whole goal was to intervene and educate the patients to use their primary care providers and to get them plugged into the resources available to them. The program helped us identify people who needed care coordination," Sesti says. For instance, one member kept coming in with chest pain. His condition was serious enough that he was admitted each time. The case managers referred him to the care coordination department, which worked with the member and his primary care physician to get him transitioned to hospice care.

In some cases, they referred members to a mental health facility or other behavioral health services.

Realizing that the case managers were working in only one hospital, some members, who were frequent emergency department users, simply switched to another hospital for non-emergent care. "Some members didn't want to be questioned about why they were in the emergency department so they just went to another hospital," Medlock says.