Taking a new tack, MetroHealth System welcomes super-utilizers of the ED, equips them with care coordinators

Care plans give ED providers a roadmap to follow when patients with complex needs present for care

The emergency medicine community has pushed hard against complaints that too many patients with non-urgent needs are being seen in the ED, but there is little doubt that so-called super-utilizers — patients who come to the ED regularly for one reason or another — are not receiving the kind of care they need in the most appropriate setting. Further, in cases in which there are finite emergency resources, such patients are taking time and space away from patients with urgent and acute care needs.

Addressing this problem cost-effectively is complicated in a fee-for-service environment that rewards volume, but as health care organizations inch toward different payer models that reward quality and satisfaction, new solutions are emerging that can help transition super-utilizers of the ED toward more effective, ongoing care pathways.

For example, the Red Carpet Care program, developed by the MetroHealth System in Cleveland, OH, is addressing super-utilizers by turning a common response to these patients on its head. Rather than viewing them as a nuisance when they present to the ED for the umpteenth time, the aim of this program is to roll out the "red carpet" to these patients by offering them easy access to care coordinators and other resources to help them connect with the kind of care and resources they really need.

Devise care plans

The program is actually just one component of larger efforts that have been going on at MetroHealth for more than two years, explains Alice Petrulis, MD, FACP, the medical director of managed care at MetroHealth and the clinical champion of the Red Carpet Care program. Beginning in 2010, the ED at MetroHealth Medical Center began sending the names of super-utilizers to Petrulis with the idea that she could set up a care plan for these often complex patients so that the ED would have guidance to follow when they come in for care.

For each patient, Petrulis tracked down the primary care provider (PCP), if there was one, and any other care providers involved with the individual's care, and they mapped out a care plan that was fairly rudimentary. "It would include things that the ED needed to know," says Petrulis, noting that the plan would point out what tests and procedures the patient had already undergone, whether the patient needed to be referred to his or her PCP, and whether the patient was a narcotic seeker.

Petrulis, who works out of the MetroHealth Medical Center, then entered the care plan into the health system's electronic medical record (EMR) under a special code, so that it would be flagged whenever the patient presented to the ED for care. "When the patient's name was pulled up by the ED physician, the name would be in red, and the provider would be prompted to click on the name to bring the care plan up," explains Petrulis.

This approach worked well, and was consequently enlarged for a project MetroHealth devised with the state's Medicaid program. "We took a handful of patients from each of the three Medicaid payers, and did the same thing," says Petrulis. "We put in care plans that would alert the ED, and we did intensive case management via the case managers at each of the three plans."

During the Medicaid project, Petrulis sat down with representatives from the three Medicaid payers every month to review each of the patient cases, update their care plans, and assess what impact the approach had made over time. "In a year, we were able to reduce ED utilization by 39% [among the super-utilizing Medicaid patients]," observes Petrulis, explaining that the statistics were calculated by comparing utilization before and after the care plans were initiated. "Indeed, many of the patients had stopped using the ED, and they were actually quite grateful. They didn't know they could just call their PCP or get an appointment that easily."

The approach delivered many success stories, but it did not work well in every case, notes Petrulis. "Patients who were alcoholics were the toughest to get a hold of, and some others were difficult to find, too," she says. "They didn't answer their phones and didn't come to clinic appointments."

However, the approach was successful enough that Petrulis is continuing this work with two of the Medicaid payers. "Every four to six weeks we go over all of the patients who are on our list, update their care plans, and talk about how to better care for these patients, improve the quality of their care, and keep their ED utilization down," she says.

Take a welcoming approach

Further, the work has formed the basis for the Red Carpet Care program, which is being funded, in part, by a grant from the Robert Wood Johnson Foundation. Building on the earlier efforts, MetroHealth has hired two nurse practitioners (NP) to serve as care coordinators and contact persons for the super-utilizing ED patients who are identified for the program.

"They actually give the patients cell phones if they don't have a phone, and the NPs tell the patients that they can call them at any time. That way, the patients are not on the phone lines waiting in some sort of tree in order to get a hold of someone they can speak with to make an appointment," explains Petrulis. "It is the same face every time so the patients can establish a relationship with that NP."

Developers have based many of the program's elements on input they received from previous patients who were super-utilizers. "We did a focus group with them before we started with recruitment for the new program," notes Petrulis. "They wanted the same face every time and they wanted someone to take care of them who would give them good care, but also like them for who they are. It was very reassuring to hear that, so we thought the phrase red carpet care' would be a very successful name for this project."

As with the earlier efforts, the Red Carpet Care program relies on the ED at MetroHealth Medical Center, a level I trauma facility that sees 100,000 patients per year. Emergency providers identify patients who would be good candidates for the program. Jonathan Siff, MD, MBA, FACEP, the director of informatics and associate director of emergency medicine operations for MetroHealth, has taken the lead in coordinating the Red Carpet Care program in the emergency setting.

"I am the person who the ED folks come to when they have someone to nominate for the program, and I communicate with Dr. Petrulis," explains Siff. "Sometimes the patients meet her criteria, but we communicate back and forth to identify patients who can benefit from comprehensive case management at the hospital level."

Target patients with complex needs

Siff adds that while there are no "hard and fast" criteria that patients must meet to qualify for the program, it is generally designed for patients who use the ED frequently and who have problems or issues that are beyond the scope of the ED to address.

"These patients are generally very challenging if for no other reason than they do use the ED so frequently, and that often creates frustration for patients and for providers," he says.

Having access to the care plans is a plus for everyone involved, adds Siff. "It is better for the patients because they know what to expect," he says. "And it is better for the providers because they have a very clear roadmap of how to address the patient's usual needs without having to try and reach a PCP at 3 o'clock in the morning, and without having to spend hours trying to review a very complicated and lengthy chart."

It can be very difficult to get all the parties involved in a patient's care in the same room or involved in the same email trail to come up with a final cohesive plan, so it often takes time to get a care plan in place, notes Siff. Social workers or case managers often need to be heavily involved because many of these patients have social issues such as language barriers or financial problems.

"Sometimes there needs to be investigation," says Siff. "We may need to call the patient and talk to him, or involve social services to go to the home and see what the situation is, so it can get very complicated," he observes. "But ultimately, I think it always improves care for the patient."

For example, through this collaborative approach, the Red Carpet Care program can make sure patients are getting their medicines and that they have access to a physician who speaks their language. "They do whatever can be done ahead of time," says Siff, referring to the care planners involved with the program. "Then if a patient re-presents to the ED, for whatever reason, the program provides us with an easy link to a plan of action that we can follow."

In addition to identifying patients who might be good candidates for the program, emergency physicians also play a role in developing the care plans. However, Siff says there has been no resistance to the approach because it helps providers deal with many of the more complex patients. "It improves our ability to deal with these patients in an appropriate and expedient fashion," he says.

Furthermore, patients are responding well to the program, too. "They have been educated by the case managers, so they have an understanding of what they can expect to have done when they come to the ED," says Siff. "Prior to the program, I think many of these patients had expectations that were unrealistic or that were fostered by some of the barriers."

Since many of the barriers have already been addressed ahead of time when these patients come in to the ED, the patients receive better care coordination, stresses Siff. "The whole idea of the red carpet approach is that we want to roll out the red carpet for these patients and put them in the control seat," he says. "If they understand what their care plan is and if they are learning the tools to help manage their own care, they are going to be healthier and more satisfied."

Sources

  • Alice Petrulis, MD, FACP, Medical Director of Managed Care, MetroHealth System, Cleveland, OH. E-mail: apetrulis@metrohealth.org. Phone: 216-778-7043.
  • Jonathan Siff, MD, MBA, FACEP, Director of informatics and Associate Director of Emergency Medicine Operations, MetroHealth System, Cleveland, OH. E-mail: jsiff@metrohealth.org.