Program helps beneficiaries avoid unnecessary ED visits
Program helps beneficiaries avoid unnecessary ED visits
Care coordination steers members toward primary care
Medicaid beneficiaries enrolled in Anthem Blue Cross' Self-Care Initiative cut their emergency department use for nonemergent conditions in half, earning the Thousand Oaks, CA-based subsidiary of WellPoint Inc. a BlueWorks Award from the Blue Cross and Blue Shield Association.
The BlueWorks awards recognize innovative ways that Blue Cross and Blue Shield companies are working to increase the efficiency and consistency of care. The Harvard Medical School Department of Health Care Policy evaluates candidates for the awards and makes recommendations.
"We know that traditional Medicaid members tend to go to the emergency department for preventive care and non-emergency care when it would be more appropriate for them to be treated by a primary care physician. With this program, we work on changing behavior and empowering our members to take control of and manage their own health," says Mary Beth East, MPH, director of health services for Anthem's state-sponsored business.
The program has observed a 50% reduction in emergency department use among members who enrolled in the program, East says.
The health plan calculated the outcomes by evaluating the emergency department use by members who had been covered by the health plan for six months before they were enrolled in the program and for six months after the interventions began.
"Engaging people in their own health care improves their own health, saves money in health care spending, and reduces pressure on local emergency rooms as well," East says.
The health plan began its ED initiative when data showed that a significant number of members were being treated in the emergency department when it would be more appropriate for them to be treated by a primary care physician, East says.
An analysis of claims data showed that the top non-emergency reasons that Medicaid members seek treatment in the emergency department are upper respiratory illness, earache, fever, and abdominal pain — all conditions that can be managed with self-care in the early stages.
"We knew we had an opportunity to make an impact and felt that education was going to be a key component in getting these people treated in an appropriate level of care," she says.
All members in the program receive information on self-management of common conditions, information about the health plan's 24-hour nurse line, and an offer to receive the Healthwise Handbook, an easy-to-understand guide with information on self-management of a variety of common ailments.
"We tried a pilot project during which we sent out a similar self-care handbook to all members, but, when we contacted the members, we found they didn't use it because they weren't expecting to get it and didn't need it at the time. Offering this self-care tool to people who have received health care services is more effective because they're expecting the book and they find it useful. We've gotten positive feedback about the book from people in the emergency room program," East says.
The organization reviewed its claims data to identify members who receive emergency treatment for conditions that could be treated on a different level.
"We looked at people going to the emergency department three or more times in a 12-month period and found that there was a pattern. We continue to look at the data on a monthly basis," she says.
Once a member has been identified as a frequent emergency department user, the information is put into a database and stratified for risk.
Level 1 members have made three or more visits and seen a physician as well during a 12-month period.
These members receive a mailing that includes information on fever, headaches, how to take a temperature, and other tips on caring for common conditions, information about the health plan's 24 hour nurse line, and a refrigerator magnet with the nurse line's toll-free number.
Members who fall into Level 2 went to the emergency room three or more times but never saw a primary care physician during a 12-month period.
They receive the same information in the mail as the members on Level 1 and also receive a telephone call from the health plan's patient education coordinators, specially trained staff who explain the health plan's services and help the members identify their primary care provider.
"This is more effective than the welcome call people get when they enroll. When somebody is new to the plan and they don't need to use the service, they may not pay attention to it. Since they have used a medical service, it's easier to engage them," she says.
Some of the members did not choose a physician at the time of enrollment and did not like the physician to whom they were assigned but didn't realize they could change.
Whenever possible, the patient education coordinators call the customer line while the member is on the telephone and help the member change physicians. If the member wants to make the change after doing some research, the patient education coordinator gives them the telephone and the instructions.
Level 3 members have been to the emergency department more than 10 times in a 12-month period and are referred to RN care managers, who work with them to get them to a more appropriate level of care.
The care managers call the members and conduct an extensive assessment to get an idea of the member's medical condition and why they are visiting the emergency department.
The care managers work with the members' primary care physicians on strategies to get the members the care they need to avoid visits to the emergency department.
They send members' primary care physicians reports on a monthly basis about each member's visits to the emergency department.
"Sometimes the physician may be treating a member for one condition but in between visits, they have a migraine or lower back pain and go to the emergency department for treatment. The primary care physician may not know that the member has sought other treatment. We try to close that gap," she says.
Anthem asks the physicians to put the member profile in the medical record so when the member makes another visit, the physician can deal with the issues.
The care management interventions depend on the members' needs and the care manager's clinical judgment.
They make sure that members with acute medical needs are connected with the specialist and that they have the right equipment in the home if they have been hospitalized.
"The member may just need to be referred to a specialist or they may need follow-up calls on a weekly or monthly basis. When someone is stable and no longer using the emergency department for primary care, the care managers close the case," East says.
When the care managers assess the patient in the emergency department program, they may refer members with chronic conditions or those who need intensive care coordination to other care coordination and disease management programs.
"We are finding people in our emergency department sweeps who are also eligible for our disease management programs. We have created an interface and link between all the programs we offer to ensure that members get the care they need," she says.
As an offshoot of the program, the health plan is working with its pharmacists on a plan to coordinate medication overlap, which can occur when members seek emergency care as well as seeing their primary care provider.
The team includes social workers who coordinate help with the member's non-medical needs, such as shelter, clothing or transportation.
"Sometimes, the members don't have a medical problem but they need community resources or in-home support. That's when the care managers refer them to the social workers," she says.
Managing the care of members on Medicaid is a challenge for the care managers because many of the beneficiaries are transient and may not have a regular telephone number.
"Sometimes, no matter how many avenues we try, we end up with a phone number that has been disconnected. I tell my staff that when they reach somebody, it's gold," East says.
Medicaid beneficiaries enrolled in Anthem Blue Cross' Self-Care Initiative cut their emergency department use for nonemergent conditions in half, earning the Thousand Oaks, CA-based subsidiary of WellPoint Inc. a BlueWorks Award from the Blue Cross and Blue Shield Association.Subscribe Now for Access
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