North Carolina program reduces rates of children’s use of EDs

Phone triage, increased availability of primary care doctors possible factors

Increased access to primary care services for children through Carolina Access, North Carolina’s Medicaid managed care plan, has been associated with a reduction in visits to the emergency department (ED) in research reported in the August 2000 Archives of Pediatrics and Adolescent Medicine.1

Specific services that may be responsible for the drop in ED visits include expanded availability of primary care physicians and use of a telephone triage system. The researchers say no similar decrease in ED use was seen among the non-Medicaid-insured group.

Carolina Access was phased in across the state in the 1990s. Medicaid recipients are assigned to a primary care physician (PCP) who agrees to provide necessary preventive care and access (at least by telephone) 24 hours a day, seven days a week. PCPs are paid a monthly fee for each Carolina Access patient on their rolls in addition to a fee for each service provided.

To evaluate the impact of Carolina Access on pediatric ED use, researchers from the University of North Carolina Department of Pediatrics, Greensboro Area Health Education Center, and Greensboro’s Moses Cone Health System conducted a population-based study in the greater Greensboro area involving the EDs at Moses Cone and Wesley Long hospitals.

Most of the area’s primary care services for children are provided by Guilford Child Health, a private corporation formerly a part of the county health department.

One smaller clinic and one pediatric practice also see children enrolled in the Medicaid program, and most private practices have a few Medicaid enrollees.

In 1995, before implementation of Carolina Access, average ED use by children enrolled in the Medicaid program was 33.5 (+/- 5.3) visits per month per 1,000 children.

That rate decreased 24% after full implementation of Carolina Access to 25.6 (+/- 2.3) visits per month per 1,000 children, and remained consistently lower throughout the study period of Jan. 1, 1995, to Dec. 31, 1997.

In contrast to the results found with Medicaid enrollees, monthly visits for non-Medicaid-insured children before and after implementation of Carolina Access increased 8% from 12.2 (+/- 1.1) visits per month per 1,000 children to 13.3 (+/- 1.4) visits per month per 1,000 children.

The researchers say the decrease in nonurgent use of the ED was even more striking, dropping 37% for the Medicaid-enrolled children.

"The decrease in total ED use by children enrolled in the Medicaid program is almost entirely attributable to the change in nonurgent visits, as urgent use declined only slightly during the study period," the researchers say.

While those who conducted the study have hypotheses about the reasons for the decline, they say that because of the nature of the study design and the fact that they did not directly measure any intermediate outcomes, any conclusions must be drawn with caution.

In theory . . .

They theorize, however, that it was implementation of two specific primary care services — expansion and identification of PCPs for children enrolled in the Medicaid program and access to 24-hour-a-day primary care availability — that brought Medicaid enrollee use of the ED much closer to that of non-Medicaid-enrolled children.

The researchers base their tentative conclusions on anecdotal information about implementation of Carolina Access.

Beginning in late 1995, two large pediatric practices each increased their Medicaid enrollment by 500 and a smaller, nonprofit clinic expanded to include 300 more Medicaid recipients. Most of the newly enrolled Medicaid recipients previously had no medical provider.

Doctors on call

It also was seen that the newly enrolled Medicaid patients made use of call-a-nurse or on-call physician services through their PCPs for 24-hour access.

In addition, Guilford Child Health, the largest care provider (more than 20,000 visits a year) for children enrolled in the Medicaid program, implemented a full telephone triage program when Carolina Access began.

Data from the telephone triage system show that it received more than 350 calls from concerned parents per month. Of the calls received, more than 70% of the callers received home care advice and did not require a referral to the ED.

"Direct data on the number of ED visits averted by this system are not available, but anecdotal reports from families and physicians lead us to believe that it is a substantial number," researchers write.

Possible other explanations for the drop in ED visits were examined. Those reasons include:

• Families used a different hospital’s ED.

• There was a dramatic increase in the number of children enrolled in Medicaid.

• Carolina Access was implemented in the midst of an existing downward trend of ED use over which it exerted no influence.

However, those reasons were not found to be valid.

Reference

1. Piehl MD, Clemens CJ, Joines JD. Narrowing the gap: Decreasing emergency department use by children enrolled in the Medicaid program by improving access to primary care. Arch Pediatr Adolesc Med 2000; 154:791-795.