Boost satisfaction: Combine ED, urgent care

Get patients best care while making payers happy

[Editor’s note: This is the first of a series on restructuring the emergency department (ED) to increase patient satisfaction, provide better patient care, and lower costs to the hospital and payers. Key elements include creating urgent care centers to handle lower acuity patients and the use of physician extenders. Look for more tips in the future on how to hire, train, and better use midlevel practitioners in your ED and urgent care centers. Another future article will look at adding an observation unit for potential acute myocardial infarction cases that will ensure patients get cardiac care fast when needed, while making sure unnecessary care is not provided to patients who aren’t having a heart attack.]

The image of the bustling ED handling everything from sprained ankles to gun-shot wounds is a part of the past in many hospitals. Replacing it are ED/urgent care center combinations that are just as busy but far more efficient, especially in terms of managed care’s stringent reimbursement demands.

These combinations improve patient satisfaction because care is received much sooner, report hospitals that have restructured their EDs. Payers also are pleased because careful triage procedures ensure that patients with less complex problems get care at a lower cost.

How does this new ED work? As soon as patients come through the door, the process begins with an experienced triage nurse who can use protocols developed by the medical staff to divert patients with less urgent conditions — ear infections, simple sprains, lacerations that need stitches — to the ED’s urgent care services.

But don’t expect such efforts to boost revenues immediately or cut costs, experts warn. However, restructuring your ED now could keep your facility competitive and profitable when payers demand lower costs for emergency care and improved patient satisfaction.

Ukiah (CA) Valley Medical Center set up such a program two years ago, and so far anecdotal evidence suggests it has increased patient satisfaction. It also has reduced payers’ costs by 25% for many less-severe conditions.

The hospital in rural northern California has 101 beds and handles 2,500 emergency room/urgent care visits per month.

The ED has seen slight increases in volume at a time when many hospitals in California have had decreases, says Ron Gester, MD, FACEP, medical director and emergency physician at the Pacific Redwood Medical Group in Ukiah.

ValGene Devitt, president and chief executive officer of Ukiah Valley, says the hospital has received numerous comments from patients that they like being able to enter the ED and not have to wait in line.

"The emergency room is always focused on the sick person first, so if you have a cut finger or a child with an earache, you don’t go to the top of the priority board," Devitt says.

"That’s where urgent care comes in, and that’s what we get the most feedback about," he adds. "People say we have much less of a wait than the last time they were in."

Ukiah has little managed care presence compared with other parts of California. But Devitt says the urgent care center also is increasing these payers’ satisfaction.

A payer that represents a large group of Ukiah employers has actively supported the urgent care center, Devitt notes.

The insurer even asked to extend the urgent care center’s hours to 24 hours a day. Urgent care closes at 9 p.m. each day because it wouldn’t be economical to have round-the clock service — yet.

The hospital hasn’t boosted its own revenues from the addition of an urgent care center, but that was never the goal, Devitt says.

"If you take the approach that these people are going to come through the emergency room anyway, then, no, we’re not making more money," he says. "We looked at this not as a financial gain but as a better way to serve our community and cover our costs."

Devitt adds, "We’re not losing money, and we’re more appropriately covering the people who come into the emergency room."

The urgent care center is within the ED, next to the traditional emergency room.

Gester, who helped start the urgent care center, says the goal is to have patients in and out within an hour.

What’s at stake? Future business, for one thing. Faster treatment times improve your hospital’s overall image and could bring increased revenues in other departments, notes Mary Anne Bruner, a spokeswoman for the emergency medicine practice department of the American College of Emergency Physicians in Dallas.

"If you have a high waiting time for people with a minor earache or muscle strain, then they might go somewhere else the next time," Bruner says.

"The emergency department is the hospital’s front door for most of the community," she adds. "And if the front door isn’t looking nice and welcoming, then when elective surgery time comes along, they might not want to go to that hospital."

Ukiah Valley Medical Center chose to combine the urgent care and ED to make it easier for the staff and patients.

Location, location, location

When planning your ED restructuring, remember that most patients will come in through one location. If the emergency room and urgent care center are in separate places, it is likely you will duplicate staff and other resources, Gester notes. Also, think about what patients in pain will think when they are told they need to trek across the hospital campus for care.

From a payer perspective, urgent care’s typical savings of 25% over a regular ED visit is attractive. But there are other benefits. For example, patients treated as part of a follow-up visit are charged even less, whereas the ED offers no cost break for a follow-up visit.

Gester, Devitt, and Bruner offer the following advice on setting up an urgent care center:

Decide what your facility needs.

Gester recommends placing an urgent care center next to the ED, using some of the same staff.

But it depends on whether your facility has extra space in the ED or adjacent to it. Ukiah Valley rearranged its emergency department to transfer some space to the urgent care center. Then some exam space was created out of office space across the hall, Gester says.

Devitt says the hospital made the changes piecemeal. "We didn’t hire outside consultants. We did it on our own," he adds. "I couldn’t even put a dollar figure on it."

The remodeling and set-up — done by hospital employees — took three-to-four months.

"We really only constructed two walls, and the rest of the work was to put in a counter here or there," Devitt says.

But administrators spent more than a year wrestling with the idea of opening an urgent care center before beginning the renovations, Devitt notes. "We were concerned that we might go to the trouble of creating extra space and extra staff, and then the volume wouldn’t be there. We had to convince ourselves that the numbers would work, and it’d be worth it."

Care center still improving

Devitt says the urgent care center is so successful that the hospital now plans to expand it. The first phase "was driven by what was available," he says. The second phase will expand the urgent care center to more than twice its current size.

Property next door has been bought that includes a building that will be remodeled for physical therapy and occupational therapy. That will free up the current outpatient physical therapy space immediately adjacent to the ED. DeVitt is still developing the budget for the second phase of the urgent care center.

Decide whether you need duplicate equipment.

Ukiah Valley again saved money by using most of the same equipment for both the emergency and urgent care services. Devitt says the hospital spent less than $10,000 on duplicate equipment that mainly included items like blood pressure devices.

With the expansion, an X-ray room might be added to the new space.

Choose a schedule for the urgent care center, and hire additional staff as needed.

Ukiah Valley keeps the urgent care center open from 11 a.m. to 9 p.m. weekdays and from 9 a.m. to 9 p.m. on weekends. As the center grows, the hospital might expand the hours.

The urgent care and emergency centers have six to nine nurses on duty at any time, including part-time nurses, Devitt says. The nurses have the same basic duties in each area.

Ukiah Valley also hired about four clerical employees, and one person is always present in the urgent care area.

Set up new codes for patient conditions.

This makes it easier for the triage nurse to switch less urgent medical conditions to the urgent care model.

"These codes are used to determine billing," Gester explains. "A fair amount of effort needs to go into how encounters are coded. Then a fee structure that makes sense has to be attached."

Devitt says physicians decided their own charges because California is a corporate practice state, which means physicians have to charge for their own services instead of having the hospital pay them.

Urgent care charges lowered

The physicians and administrators took a look at the current ED charges for low-end services and brainstormed about how to modify them. Their initial goal was to make the charges comparable to what patients would be charged in a physician’s office for the same conditions. "We were not able to do that," Devitt admits. But the hospital has lowered urgent care center charges by 25% from the emergency room charges.

Once codes were established, the hospital created positions for triage nurses who decide where to send patients as they enter the ED door. The nurses compare patients’ conditions to the new codes for urgent care and emergency care.

Ideally, the triage nurse has years of nursing experience and is a certified ED nurse.

"They’re all trained to err on the side of safety," Devitt says. "If they see something that they’re not sure of what to do, they’ll refer that patient to the emergency room side. The triage nurse is not authorized to turn away any patient."

Patients who enter the ED find the triage nurse in the center; to the nurse’s right side is the urgent care center, and the emergency room is to the left.

Set up a protocol for midlevel practitioners.

Bruner suggests you start with the American College of Emergency Physicians’ guidelines and sample job descriptions for the roles of physician assistants and nurse practitioners in emergency departments. (See midlevel practitioners’ guidelines, p. 103.)

"The college’s main concern is that emergency physicians should be involved, and the protocol drives this," Bruner says.

Encourage collaboration between physicians and midlevel practitioners.

"It leads to the best quality of care, and it increases satisfaction of both groups of providers," Gester says. (See story on hiring midlevel practitioners, below.)

Ukiah Valley Medical Center had good luck finding midlevel practitioners because a few emergency nurses decided to be trained as nurse practitioners about the time the hospital was establishing its urgent care center. When the center opened, these midlevel practitioners worked for it.