Health plan cuts ED as primary care

Members learn appropriate venues

An initiative to cut down on the use of the emergency department (ED) for non-emergent care by educating patients on more appropriate levels of care resulted in an 11.5% decline in ED use in three years by members covered by Blue Cross and Blue Shield of Florida, with headquarters in Jacksonville.

"We knew we had a lot of patients who were seeking care in the ED for diagnoses that could be treated more appropriately in the primary care setting, such as upper respiratory infections, abdominal pain, sore throats, and pink eye. We are focusing on how to get patients out of the ED and into the primary care clinic or a convenience care clinic when they need treatment for minor illnesses," says Uday Deshmukh, MD, MPH senior medical director for Blue Cross and Blue Shield of Florida.

The focus on the program is to help patients learn to utilize the appropriate level of care and to facilitate patients receiving care at the primary care level. "We want to make sure that our members have a relationship with a provider of their choice who can take care of their primary care needs and facilitate preventative care services," he says.

The health plan utilized its claims data to determine which members have gone to the ED instead of seeking care in a more appropriate setting and began a program to educate them about alternatives to an ED visit. As part of the initiative, the health plan doubled the size of its network of urgent care centers and sent members information about the importance of seeing a primary care physician or going to an urgent care center instead of going to the ED. The information includes location and hours of operation of the centers in their area and examples of situations in which urgent care would be a safe alternative to EDs.

Members who are frequent users of the ED receive a telephone call from members of the health plan's Care Consultant Team, who educate them on the availability and hours of urgent care centers in their area and help them identify a primary care physician or specialist, if needed. Members of the Care Consultant Team are a combination of clinical staff and non-clinical staff who have been trained in engaging members over the telephone.

The team also receives calls from members with questions about their diagnosis, their benefit plan, and what resources are available to them through their insurer. They may want information about how to seek care for a particular decision and help in deciding what facility is the best option for them based on their benefits. Sometimes patients who are newly diagnosed with a condition call with questions about what they should do. Deshmukh says: "In many situations, members who use the ED for non-emergent situations would benefit from being engaged with case management or disease management programs. In these cases, the care consultants call the members and discuss the programs that are available to them."

The care consultants work with the member to find out if they need community resources such as transportation assistance to travel to their primary care provider's office or financial aid for prescriptions to keep their conditions under control and avoid trips to the ED. When members with chronic conditions visit the ED, the care consultants contact them and offer them the opportunity to enroll in case management or disease management programs.

Some patients go to the ED because they don't have a primary care physician, or they get sick at a time when their primary care clinic isn't open, Deshmukh points out. "We try to understand the root cause of their emergency department visit and provide the type of information they need to establish a relationship with a primary care physician and seek care in an appropriate venue," he says.