Changing client behavior is top challenge for decreasing ED use

There is no question that decreasing inappropriate use of the emergency department for Medicaid patients can save significant costs, but getting results is a daunting challenge.

Currently, 20 state Medicaid programs are utilizing grants from the Centers for Medicare & Medicaid Services (CMS) to provide alternative health care settings for nonemergent needs, with the goal of decreasing ED use. The funding comes from the Deficit Reduction Act of 2005, which provided $50 million to be distributed over four years (2006-2009) for primary health care programs. For the most part, the programs are located in rural and other underserved areas.

In Georgia, four grants were made to partnerships of primary care providers and hospitals to develop a primary care access point for nonemergent ED patients. Each developed its own nonemergency protocols. The grantees are in the early stages of implementation, but to date, 4,929 patients have been treated in the new primary care nonemergent centers.

"All patients receive the same screenings regardless of medical coverage," says Jerry Dubberly, chief of Medical Assistance Plans and director of Medicaid for the Georgia Department of Community Health. "In general, a patient seeking treatment from a hospital ED for a nonemergent condition is encouraged to seek care from a primary care provider, which may be the primary care center funded under the grant."

Education is key

Washington Medicaid hasn't yet formally evaluated its program to decrease ED use, but changing client behavior is proving to be a significant challenge. "The strategies make sense in terms of after-hours care and providing alternatives for individuals. But there is a huge client education component to this. We need to help people to think of alternative ways to seek care," says MaryAnne Lindeblad, Medicaid division director.

Ms. Lindeblad says in the long term, she expects to see more tangible results from the state's new focus on person-centered medical homes. "That will provide a better delivery system and will give folks 24/7 access to someone or something. I think that will probably be more successful in the long run than some of these more narrowly targeted interventions that we have been able to make so far through the grant."

Most of the communities with initiatives in place are looking for ways to manage what is often referred to as the "frequent-flier" population. These individuals often need additional care management, and they need to be linked to providers and community resources for after-hours care. "I think there will be some good things coming out of the grant," says Ms. Lindeblad. "But in the end, we need to give folks a place to go to, so they can see somebody in the time frame that they believe they need. And we need to give them self-management strategies, too."

The first step is to provide some education to Medicaid clients, who don't always understand when it is appropriate to use an ED. "We were able to get a fast-food restaurant to put information about ED use on the paper placed on their trays. And we are looking at doing this at other places where low-income families might go," says Ms. Lindeblad.

Appropriate alternatives needed

The Georgia Department of Health encourages Medicaid members to establish a medical home by choosing a primary care physician as soon as possible. According to Mr. Dubberly, "the biggest challenge is changing member behavior to seek care in the most appropriate setting. Over the long term, we hope to see healthier Medicaid members who establish a medical home and fully utilize their benefits for preventive care rather than urgent care."

Utah's Emergency Room Diversion Grant of $503,000 was used to provide an intervention to identified clients who used the hospital ED for nonemergent care. The population was initially limited to people in the Wasatch Front, an urban area, but has since been expanded statewide.

Patients are encouraged to seek care from a family practitioner or physician at community health centers and are informed of instances when it is appropriate to visit an ED. One of the goals was to attempt to determine why patients decided to visit the ED for nonemergency care instead of their physician or community health center.

"The intervention is geared toward changing a client's behavior," says Gail Rapp, director of the managed health care bureau. "There are three levels of intervention." These are as follows:

1) When clients have a first nonemergent use of the ED, a friendly letter is sent that educates them about the provider choices available of a primary care physician, an urgent care center, and a hospital ED. They are instructed to choose the most appropriate facility for their care. "A list of urgent care facilities in Utah is included," says Ms. Rapp. "Also, staff offer clients help in finding a primary care provider."

2) Clients are sent a second letter when there is a second nonemergent use of the ED. "The second letter is more direct, and warns the client that continued use of the ED for nonemergent care may warrant enrollment in the Medicaid Restriction Program," says Ms. Rapp. A list of urgent care facilities in Utah is again included with the letter.

3) A third nonemergent visit to the ED moves a client into review status in the Restriction Program. "A standard Restriction Program letter about misuse of the ED is sent to these clients," says Ms. Rapp. "Once enrolled in the Restriction Program, the client is assigned a single primary care provider and pharmacy."

Full evaluation of the program's effectiveness will be completed during the second quarter of 2010. "It is our goal to show a reduction in nonemergent use of the ED in the group that received the intervention," says Ms. Rapp. "The biggest challenge is locating appropriate alternatives where people can go for urgent care rather than rely on the ER."

A questionnaire sent to clients revealed that a large number of respondents were not aware of an urgent care provider in their area. To address this, a questionnaire was sent to all Medicaid contracted group providers statewide asking them if they offer urgent care, extended hours beyond Monday through Friday from 8 to 5, and if they see patients without an appointment.

"We've received a good response from the providers, and we are building a database of urgent care providers," says Ms. Rapp. "Over the long term, we hope to see increased awareness by both patients and doctors of the urgent care providers in the community."

Another problem revealed by the client questionnaire was that a significant number of clients were told to go to the ED by their primary care doctor. "We would like to see doctors suggest using an urgent care [center] when they feel their patients should not wait for a regularly scheduled appointment in their offices," says Ms. Rapp. "We believe providing information about alternatives to using the ED to the decision maker—the patient—will result in a reduction in using the ED replaced by a rise in using urgent care."

Innovative communication

"Decreasing nonemergent emergency room visits is a key component in improving health outcomes and decreasing Colorado Medicaid costs," according to Sandeep Wadhwa, MD, state Medicaid director. The Department of Health Care Policy and Financing began efforts to decrease the improper use of emergency departments (EDs) in 2008.

In 2008, the department was awarded a grant from CMS of $1.8 million over a two-year period. The goal of the funding was to explore ways to improve access to primary medical care, so that Medicaid clients could avoid improper use of EDs and receive proactive, preventive care rather than waiting until conditions become exacerbated. The department granted these funds to two community health centers, Valley-Wide Health Systems and Peak Vista Community Health Centers.

The Convenient Care Community Clinic opened by Valley-Wide Health Systems in November 2008 has averaged more than 1,000 visits per month, with Medicaid clients comprising one-third of these visits. In one year, more than 300 people with nonemergent conditions were deferred from the ED to the clinic. About 12,000 additional people chose to make appointments at the clinic without going to the ED.

Peak Vista Community Health Centers collaborated with a local hospital, Memorial Health Systems, to station staff in the hospital's ED during the busiest hours of the week. After a client has been seen in the ED, staff explain the availability of primary care and how this improves overall health and reduces the need for emergent care.

In one year alone, Peak Vista has connected with more than 7,000 people visiting the ED at Memorial Health Systems, with follow-up appointments offered at the clinics. "Of the people contacted, 2,000 made and kept clinic appointments," says Dr. Wadhwa.

Peak Vista has provided immunizations to more than 300 children who were referred from the emergency room, and provided routine primary care tests to 130 clients with diabetes, who were referred from the ED. "These clients now have a medical home and will receive primary, preventive care," says Dr. Wadhwa. "The department's focus is on maximizing the health of our clients, ensuring timely access to needed services and maintaining the affordability of care. Implementing efforts to decrease nonemergent, emergency room visits is one of the ways we are supporting the value of having a medical home and receiving preventive care."

Direct communication with clients is accomplished through a variety of innovative methods. A survey was conducted at nine hospitals to determine what prompted the client to visit the ED. The most common response was that clients thought their condition was serious. About 80% of respondents said they would talk to a nurse over the telephone about their condition before going to the hospital.

"The results from the survey provided key information for the development of a plan to decrease nonemergent emergency room visits, and they serve as a baseline for future evaluation," says Dr. Wadhwa. The 24-hour Nurse Line is being broadcast on the department web site, included in all eligibility correspondence to Medicaid clients, and will be on all Medicaid benefit cards beginning January 2010.

After identifying high emergency room utilizers, letters have been sent to clients who have visited an emergency room at least six times in nine months. The letters informed clients of the availability of the Nurse Line and its value to them personally, such as no waiting time, no need for baby-sitters, and less cost. It provides a telephone number to help them find a primary care doctor.

There is a long-term plan to give hospital incentives using ED visits as an indicator, which would be made possible through the Colorado Health Care Affordability Act. "Budget cuts have not, and will not, affect the innovations for decreasing emergency room visits for nonemergent care," says Dr. Wadhwa.

Contact Mr. Dubberly at (404) 651-8681 or jdubberly@dch.ga.gov, Ms. Rapp at (801) 538-6342 or gailrapp@utah.gov, and Dr. Wadhwa at sandeep.wadhwa@state.co.us.