By Melinda Young, Author

Sentara Medical Group in Norfolk, VA, developed a plan to reduce ED utilization and readmissions. The organization’s risk-sharing contracts provided an incentive and extra boost to its efforts.

The organization’s seven-day follow-up strategies produced positive results: ED visits were cut in half in one pilot program, says Alverta Robinson, RN, BSN, MSA, RN-BC, LNHA, director of ambulatory care management at Sentara Medical Group.

“We had 17 patients in the pilot, and 16 of the patients represented 61 ED visits and 15 hospitalizations,” Robinson says. “Post-pilot, we went from 61 ED visits to 30 ED visits, and from 15 hospitalizations to 12 hospitalizations.”

The organization’s success was a direct result of its targeted program to reduce ED visits.

“We did this ED reduction strategy, and we were able to reduce ED visits by 50%, just from doing analyses of data that showed when people went to the ED, why they went there, and our trying to mitigate that,” Robinson explains.

It is better for patients if they do not present to the ED repeatedly for preventable health episodes. Health systems can more easily adopt these preventive measures if payer contracts are aligned with this quality goal.

“We have risk-sharing contracts with payers, and ED utilization is on all of those contracts, so we’re incentivized to reduce ED utilization,” Robinson says. “But even before risk-sharing contracts, we started looking at our ED utilization because in our region, ED use is very high — I think it’s because of the proximity of our hospitals.”

Here’s how Sentara Medical Group reduces ED visits and hospital utilization:

• Triage patients in ED. “We tackle the ED as two tracks: You have emergent need or a nonemergent need that could have been managed in another, lower-cost setting,” Robinson says. “We have people going to the ED for medication refills and earaches, and the payers determine what is a nonemergent visit.”

For example, vertigo and dizziness are nonemergent, even though they can be scary, she notes.

Some patients with nonemergency issues may not be able to get the imaging they need in an urgent care center or doctor’s office. Or they might benefit from a referral to a specialist, but they are unwilling to wait for that appointment. It takes some work for a health system to make patients understand that they’re using the ED for the wrong reasons.

“So we give our patients options,” Robinson says. “They can have a same-day visit with their provider, or we can refer them to urgent care.”

However, this change alone did not achieve the best results, she says.

“We were not meeting our target for ED utilization, so that made us do a deep dive, look at our population and why people were going to the emergency department,” Robinson says.

• Identify patterns. Daily reports of ED visits and hospitalizations can help case managers identify and follow patient trends.

“For example, we receive a report that says, ‘Here are your patients attributed to our medical group that had an emergency department visit within the last 24 hours,’” Robinson says. “The first step is to analyze the data, looking for patterns and trends.”

One pattern would be a consistent finding of nonemergent visits to the ED. This trend suggests there should be more education to patients in the ED about finding alternatives. They might be open to same-day appointments, she explains.

Another way to educate patients is to call them right after their ED visits to ask them how long they waited.

“Then, I say, ‘Here are some alternatives to the emergency department. We don’t want you to sit in the ED for a long period of time,’” Robinson says.

ED population patterns are helpful to identify, but so are individual patterns and trends.

“We look at the frequency of visits,” she says. “If you have had three or more visits in the last six months, then you’re on the list to be targeted for calls.”

• Follow up with patients. Case managers can introduce themselves as agents of a provider practice and say they are calling to check up on the patients, Robinson suggests.

“Patients feel good about having someone from the practice checking on them,” she says. “Our care managers are assigned to different practices and have good relationships with providers and staff, and they work with us to fit that patient into their schedule.”

Case managers also can ask high utilizers these questions:

- Do you experience shortness of breath?

- Is your condition controlled or uncontrolled?

- If it is uncontrolled, can we schedule an appointment for you to meet with your primary care provider?

• Act on the information. With patients’ permission, they set up a call schedule to check on patients.

“We try to establish that relationship and follow them for 30 days,” Robinson says. “Some older patients like the idea of having someone call to check on them.”

These calls can address their individual hurdles to seeking medical care from primary care settings instead of the ED.

For example, transportation can be provided to primary care appointments, Robinson says. “We have an agreement with a cab company, and sometimes their insurance will cover the costs of transportation, and they didn’t even know that.”

Other reasons why people go to the ED could be medication-related (e.g., to refill prescriptions). Case managers can help these patients find medication assistance through pharmaceutical company vouchers that reduce prices.

Housing also could be an issue.

“I have RN care managers and licensed clinical social workers on our team. We make referrals to social work to find housing and to help patients get food from a food pantry,” Robinson says.

There also are behavioral health issues and other social determinants of health that could affect patients’ access to primary care. Case managers help them address all of these.

Another trend is that congestive heart failure (CHF) patients sometimes take in too much sodium on holidays. Care managers call CHF patients to ask about their condition and see if they need a medication adjustment.

“We call patients and they report their weight to us,” Robinson says. “Depending on how they’re doing, physicians may give them an extra dose of medication to prevent a fluid overload that puts them in the emergency department.”

• Concentrate on frequent fliers. Payers send out a list of ED frequent fliers, asking the team what they can do to reduce their visits, Robinson says.

“I say to my team, ‘If there’s someone who has had six visits to the emergency department, and these are visits to manage a clinical problem like high blood pressure or diabetes, these are the patients we need to try to impact,’” Robinson says.

Some ED frequent fliers experience circumstances that cannot be mitigated. For example, one patient shows up in the ED twice a month because his feeding tube keeps falling out, she notes.

“He’s not a surgical candidate, so there’s not anything that can be done to correct this,” she adds. “He can live at home, but needs this feeding tube because there’s something wrong with his GI tract, and so he’s going to have ED visits.”

Another patient needs dialysis but could not go to a dialysis center because the freestanding centers in the area had forbidden him from returning because of behavioral issues.

“He needs dialysis three days a week and has to use the ED to get his dialysis, so there’s not anything we can do about this case,” Robinson says.

Case managers called all of the dialysis centers to see if they could get him an alternative for his care, but they did not agree.

“We can’t solve every problem,” Robinson says. “We will do the best we can to mitigate every issue, including transportation and medication assistance, and we’ll track patients’ medical conditions, but there are some things we’re not going to be able to fix.”

One of the success stories was a patient who had 27 ED visits and three hospitalizations within one year.

“She was beginning to have dementia,” Robinson says. “She had children who lived in her home, and we tried to figure out why she went to the ED.”

The case manager visited her home and found that the patient could not self-medicate; she either took too much medicine or too little. The case manager set up pill boxes for the patient and taught the family how to fill them.

Even after setting up the pill boxes and educating the patient’s family, the ED visits continued because her family was not engaged in helping her. The case manager took it a step further and would take an hour each week to visit the patient and refill the pill boxes.

“Then the emergency department visits stopped, and the hospitalizations stopped, too,” Robinson says.

• Provide follow-up. “We’ve taken another step and are looking at these payer reports, which is huge,” Robinson says. “We look at what insurance resources are available and whether they provide coverage for behavioral health and substance abuse management.”

The team works with payers to reduce utilization by increasing access to medication and treatment. For example, one infectious disease patient could not afford the costly antibiotic and ended up in the ED, Robinson recalls.

“People could be discharged on medication they can’t afford,” she notes. “The medication might be best in class, but if a patient can’t afford them, then you have to do something else.”

One strategy is to talk to physicians about prescribing affordable insulin and antibiotics, such as generic drugs. For instance, some big-box retailers offer $4 generic medications, she says.

Pharmaceutical medication assistance is provided to people at the poverty level, but it’s of less benefit to the working poor, Robinson says.

Still, case managers can work with pharmaceutical companies to cover medications that are not in the formulary but will prevent costly ED visits and hospitalizations.

“The care manager told the insurer to pay for the hospitalization or cost-share the medication,” she says.