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ED facilitator promotes quality, cost-effective care
Faced with unacceptably high hospital admission rates for members of their senior insurance product, a community health plan has developed a new program to reevaluate possible hospital admissions in the ED, arranging appropriate alternative dispositions when possible.
The Fallon Community Health Plan’s (FCHP) Facilitator Program places a "facilitator"a primary care physicianin the ED at St. Vincent’s Hospital, which sees approximately 65% of FCHP patients, to aid ED physicians in determining appropriate admissions, says Charles S. Mills, MD, Associate Medical Director for FCHP. The program, open 7-8 hours a day, seven days a week, also uses a case manager and social worker to set up alternative dispositions and make the necessary arrangements directly from the ED.
"What happens is, many of the patients are frail and elderly and have issues that are not medically based but complicate the medical decision making," says Mills. "They live alone, they can’t get their meals brought in. All of those contingencies are what push patients into the hospital, but that’s not really what creates a hospital-based need."
The program not only clears the path to meet those other needs and avoid an unnecessary hospital admission, but it has allowed the health plan to see where the gaps are in terms of service to their members, he says.
The motivation for the program began three years ago, when, as more plans entered the Medicare risk market, FCHP’s competition began to get more complex, says Mills. "The premium was flat, the growth rate was flat, and the competition was stiffening in terms of the capacity of our premium to be cost-effective."
Their rates of hospitalization per 1000 hadn’t moved in the last five or six years, and when they were compared to benchmarks across the county, managers found they were too high.
"We had a particularly exorbitant number of admits per 1000 when you looked at the senior plansomewhere in the range of 290-300 admits per 1000," says Mills. The baseline standard for a well-managed health plan in Medicare risk would be about 200 admits per 1000, he notes.
For other health plans, the solution may have seemed simple, Mills says. "The easiest thing to do would have been to shoot a cannon at the area where you expect [the admissions] to all come in and say, The fault is the ED and that’s how people get into the hospital.’ But the reason they end up in the ED is the reason they are in the hospital, not because the emergency department exists alone."
Fallon began by looking at what caused the admission rates to be so high.
Again, the culprit was conditions that were too severe for discharge but did not necessarily require hospitalization.
"One of the most difficult situations is the elderly, frail person who falls but doesn’t necessarily break their hip, but they have bruise and can’t walk, or they sprain their ankle and can’t walk," says Paul Gramling, MD, FACEP, Chief of Emergency Medicine at St. Vincent’s. "They don’t have much in the way of backup resources at home."
One of the most taxing decisions of an emergency physician is what to do with an elderly patient who presents with what would be a minor complaint, but they can’t deal with it, Gramling says.
"You know that if you send them home, there is a good chance they are going to wind up on the floor again, this time with a broken hip," he says.
An alternative disposition for these patients might be able to be arranged with the patient’s PCP, but Fallon found that too often the primary care physician was willing to "turf to the decision" of the emergency doctor rather than go into the ED and see the patient, Mills says.
The lack of experience some emergency physicians had with this population was another reason Fallon felt it would be beneficial to have another physician in the ED.
"A lot of times you have residents down there who don’t have any longitudinal skill mix other than their experience in the hospital setting," says Mills. "These are the people that are making the decision that Mrs. Smith must come in [to the hospital] because her CHF is so unstable. You are using the wrong point of authority to make the decision."
The facilitating physician is a Fallon group practice physician, experienced in primary care, who is paid a "moonlighting" fee to work in the department.
By looking at the distribution of the occurrence of the activity, the times when admissions were the highest, Fallon decided the program would be in effect from 1-8 p.m. on the weekdays and 12-8 p.m. on the weekends.
In addition to the physician, a social worker was hired to work in the department during the times the program was operating to facilitate transfers and admissions to other facilities or arrange home health care.
Nurse case managers also provide much of this service, but the social worker can go above and beyond what a case manager may do, says Deborah Lynne Spiro, RN, Assistant Director of Case Management at St. Vincent’s.
"Really, the social worker can do the Medicaid and the financial piece. Here at St. Vincent’s the case manager acts as coordinator of care," she explains. "We would set up the visiting nurses [because] the social worker can’t call the VNA . . . . We define the roles and they call whoever is needed."
The social work component is also not confined to just the Fallon patients, Spiro says. "We can do this for any patient. We have some patients that have required long-term placement that have no qualifiers at all and just require custodial care, and, if all their financial records are in place, we’d be able to place them right from the emergency room."
When a Fallon patient presents in the ED, they are triaged and seen just like any other patient, says Spiro. If the patient is a candidate for admission, the ED physician would determine whether or not the patient is seen by the facilitator.
"Anybody that is a surgical candidate, orthopedics, ICU admissionsanything that is a clear-cut admission to the hospitalis excluded," she says. "The facilitator doesn’t need to get involved then, unless he or she can do anything to expedite for the emergency room, diagnostic testing, consultations, etc. That is the second role they play."
If a patient is seen by the facilitator, they are examined and a decision is made between the ED physician and the facilitator about whether an admission is warranted or another disposition can be made.
Importantly, it is the ED physician who has the final word about whether a patient will be admitted or not.
"There are some conflicts, particularly over chest pain," Gramling says. "But that doesn’t happen very often. It’s the exception rather than the rule. We kind of talk that one out and think about it some more."
If the ED physician and the facilitator agree, the facilitator moves to the next step.
"They would discuss it with the patient and family and get the case manager and social worker involved at that point," Spiro says.
Fallon owns two nearby health care facilities for seniors and, often, the patients can be seen there.
Dehydrations, pneumonia, IV antibiotics, and people with chronic lung disease frequently get their care at Providence House, an adjacent nursing home owned by Fallon, says Gramling.
"The patient’s mode of getting to Providence House right next door is just going through a tunnel on a stretcher," he says.
Establishing the cost-efficiency of the program is complicated, admits Mills. Counting the salaries of the social worker, the physicians, and moonlighting fees, the baseline cost to the plan is about $250,000 per year.
The estimates of what is saved are based on estimated cases diverted from the hospital, says Mills. And their most conservative estimates indicate they are saving $1.5 million to $2 million per year.
The conservative estimate considers that the average hospital admission engenders at least one and a half to two days stay in the facility. Many of these diagnoses have an average LOS that is longer, Mills notes, and the costs and related savings could be even higher.
Fallon does extensive follow-up on the patients who are diverted from the hospital, Mills explains. The follow-up includes calling everyone the following day to make sure the arrangements made by the program were carried out.
"Basically, all the patients are put into a log, and the following day, every single patient who is diverted to an alternative care setting, be it to a plan of home treatment or clinic follow-up and testing, is followed up to find out if the testing was arranged, the appointment set, the appropriate follow-up made, and to make sure the patient is stable," he says.
The plan has tracked its recidivism rate related to their decision making and found recidivism to hospital admission of less than 1%.
There was some early objection by the ED physicians to the placement of facilitating physicians in the department, say both Gramling and Mills, but over time they have both learned to work together.
"The biggest concern was over who would have the final word," says Gramling.
The spirit of the program was originally intrusive, admits Mills. "There was this message that We don’t trust you.’ This type of message obviously doesn’t sell really well, especially if you are trying to get compatriotship and work together."
Over time, as the physicians have seen that the patients get appropriate care and follow-up, the attitudes have changed, he says. And, the health plan has learned some lessons as well.
"We changed our attitude," he says. "We realized that it was not all the ED doctors’ fault. They are part of the process, and the process involves getting accountability from the providers on the outside. If they cannot be confident that the [VNA] nurse is going to show up at 3 a.m., then they shouldn’t send the patient home."
St. Louis Children’s Hospital CARES
Children’s After-Hours Referral Emergency Services unit attracts primary care physicians, resolves conflicts with prior authorization, long waits in the ED.
What began as a measure to market the hospital to area primary care physicians has turned into a new model for delivering after-hours and emergency pediatric care at two hospitals in the metropolitan St. Louis area.
St. Louis Children’s Hospital, an urban, downtown hospital, wanted to entice primary care physicians into sending their patients there, but they were struggling with a perception that the waiting times in the ED were too long, says Douglas Carlson, MD, FAAP, Director of the St. Louis Children’s After-Hours Emergency Services Unit and Director of Pediatric Emergency Medicine at nearby Missouri Baptist Hospital. "The belief of the administration is that [the ED] is sort of the front door to the hospital, and if we could get them in here, then they would use other services."
To resolve the crowding situation in the department, they came up with the concept of establishing a referrals-only unit, to be open during the peak hours of the department.
"It is a service for primary care physicians to refer their kids with emergent medicine needs for evaluation," says Carlson. "The patients are pretriaged and referred in. We deal with anything. If a patient shows up with an urgent or emergent complaint without a referral, they are seen in the main ED. If a doctor, or agent of the doctornurse or nurse practitionerrefers the patient, they are seen in the CARES unit with an urgent or emergent complaint."
The majority of complaints treated in the unit involve respiratory distress, complications of asthma, pneumonia, bronchitis, or RSV, says Cori Miller, RN, the former coordinator of the CARES unit at Children’s. Other conditions include surgical needs, such as appendicitis and small burns, and extreme symptoms of the virus that is going around at the time, she says.
"It’s very seasonal. If it’s a GI-related virus, you have kids that can’t stop throwing up and get dehydrated. We rehydrate them," Miller says. "If it is a respiratory virus, kids can’t stop coughing and have trouble breathing."
The only things the unit excludes are multiple major trauma and children with physiological instabilities.
Since opening in August 1994, the unit has had a major impact on the hospital. The hospital had "targeted" a group of physicians it wanted to increase their utilization of the hospital. Surveys have shown that they have increased their use of the facility across the board, and not just in use of the CARES unit, says Carlson.
The wait times for the unit are significantly lower. Eighty percent of the patients are seen by the physician within 15 minutes of arrival, and 45% are in and out within an hour, he says.
"Every year we go through this [mandate] to cut the budget 10%," says Carlson. "People naturally look at the CARES unit, but the administration says no, they have to find another way."
An important boon to the unit’s success was that it didn’t require any new space to be added to the ED at Children’s. The unit simply shares the space occupied by an ambulatory procedures center during the day. The CARES unit only operates from 5 p.m.-11 p.m. on weekdays and noon-11 p.m. on weekends, and the procedures center is closed during that time.
"Because there was no new space involved, the only thing that took time when we developed it was marketing it and negotiating with the people who used the space in the daytime," says Carlson. "We convinced them that we could use the space without hindering each other. There was essentially no modification except bringing in some equipment that they needed that we didn’t have."
The ambulatory center is one large, open space, which contributes to their ability to save time when seeing patients. By seeing the patient at the same time as the nurses and registration, Carlson says he is better able to gauge what he should do next. "When someone walks into the unit, they are visually identified by every caregiver there," says Carlson. "I think that makes a huge difference in terms of how fast we greet the patient and in terms of patient satisfaction. It’s not like the ED, where there is this wall between you and the patients and you don’t even know they are there until they are put in a room.
"In the ED, my first indication that a patient is there is a tracking board that says see the next one,’ and they may have been there an hour and a half before that."
Registration and triage are performed at the same desk at the same time to limit any unnecessary delays, says Miller.
"The patient is referred by the doctor, but we still do our own triage here," she notes.
The model was so successful that Carlson is starting a similar unit at Missouri Baptist, which currently does not offer pediatric emergency services.
During peak hours in Missouri Baptist’s ED, children will be seen in the Pediatric Emergency Services Center, which was created using space shared with the hospital’s endoscopy lab across the hall.
"We’ve been able to sort of start a pediatric emergency department without any construction or remodeling," says Carlson.
The unit is staffed with one physician, two RNs, a tech, and a secretary/registration clerk.
Of all of the components, the nursing staff is probably the most important in terms of the unit’s ability to work efficiently, says Carlson.
"It really requires someone who has a fair amount of experience in not just pediatric nursing, but emergency nursing or pediatric emergency nursing," he explains. "For it to work efficiently, you need nurses who are comfortable with procedures. It would not work if I had to start drawing blood and starting IVs and things like that. A small but highly skilled nursing staff is essential."
Carlson says he routinely brings in physicians who don’t work in the unit all the time, yet are comfortable with children and have strong diagnostic skills.
"I think I could put any competent physician in there who feels comfortable around children and the place would run well because of the nursing and support staff."
Standing orders also increase the nursing staff’s ability to move the patients quickly and expedite their treatment, says Miller.
"The original attending that opened the unit wrote standing orders for specific symptoms that we used as a guideline. We don’t have anything very exaggerated, just enough to speed up the treatment," she says. "For example, if a physician called in a child and we were supposed to determine whether he had appendicitis or not, we have a standing order for the blood work, and we could go ahead and draw the blood even if our physician hadn’t seen the child yet."
The nurses have also been trained in doing respiratory treatments for asthma exacerbations or allergies, she says. "If a child comes in, we can pull the physician out of a room and say, Listen to this child.’ He will listen with a stethoscope and say [whether treatment should be started]."
Before, a respiratory therapist would have to come down to the department and give the treatment, she says.
When designing the unit, the management was concerned that, with the physicians referring children in, they would end up with the rich vs. poor emergency departments, says Carlson.
"We were worried this would be the insured ER vs. the uninsured ER, but it has turned out to not be that way," he says. The unit sees about 45% Medicaid patients, with the balance divided between HMO and other private insurance and a small portion of uninsured patients.
Carlson attributes this aspect to the location of the hospital and the fact that the physicians downtown see a wide spectrum of patients that they in turn refer in.
In other areas, the situation may differ.
The ED at Children’s saw almost a 20% decrease in volume between October 1995 and October 1996, when the state of Missouri put its Medicaid patients into managed care.
But, the CARES unit has seen steady growth of about 25% a year every year it has been open, Carlson says.
In making an educated guess, Carlson says the staff has looked at the ZIP codes of referred patients and determined that probably about half would have gone to Children’s anyway, and about half would have been referred to another facility by the PCP if the unit was not attracting the business.
"I know most of the referring physicians reasonably well and their comment all the time is that they are convincing the parents to bypass the local hospital that they may be closer to, to come down here because of this service," he says.
Patient and physician satisfaction has been phenomenal, says Miller, noting that in one month the unit received seven letters praising the service from satisfied parents of children who were treated there.
"We have had a lot of parents who specifically ask to come back here," she says. "We have physicians who tell us that the patients preferred to come to us and that they would wait, if the child’s condition was not severe, to call until we opened because the parents would not take the child to the main ER."
The unit initially had parents who brought their children to the unit without referrals, although most parents understand the process now, she says.
"It took a while to hammer out how to handle that," she notes. "At first, because of the bed control situation, [the hospital] wanted them sent through the main ED with instructions to call their physician first next time. But, for PR purposes, what we eventually started doing was putting them in a bed and calling the physician for them and getting the referral. We would then tell them that it was not something we should be doing, and that, in the future, they needed to call the physician themselves."
Most of the parents do call their physician now, and they appreciate not having to deal with a call for authorization once they get to the ED.
"They’ve already got their referral, the insurance will cover it, and their child is getting seen. There is not someone standing in the door saying, Sorry.’"