Under the gun to act, hospitals in Washington state put their hopes on seven "best practices" to curb non-emergent use of their EDs by Medicaid patients

Hospitals aim to show progress quickly; administrators hope it will be enough to head off draconian cuts

Every day patients flock to EDs with sore throats, headaches, and other non-emergent problems that are more in line with what you would expect a primary care provider (PCP) to handle. It costs more to handle minor problems in an acute care setting, but for a variety of reasons, this type of utilization continues to rise, often times clogging throughput and driving up ED wait times.

While virtually every state is concerned about the costs associated with this problem, legislators in Washington state have put the hospitals there on notice that they aren't going to put up with what they see as overutilization of the state's EDs much longer. After first announcing plans to limit Medicaid payments to EDs for visits or conditions deemed not medically necessary or appropriate in the ED setting, legislators have now backed down on that pledge, and instead have agreed to a proposal put forth by emergency physicians aimed at curbing use of the ED for non-emergent needs.

The plan involves a collaborative effort between ED physicians and hospitals to beef up the sharing of information electronically, deliver education to patients about appropriate use of the ED, and to continually monitor performance on a range of metrics so that significant reductions in ED use can be achieved by January 2013.

While no firm targets have been stipulated, hospital and ED administrators know they are under the gun to make progress quickly. It is also quite clear that colleagues in 49 other states feel like they have a lot riding on the effort as well. (Also, see "New Jersey effort brings down non-emergent utilization at two demonstration sites, but findings suggest more policy changes are needed," below.)

'Best practices' take center stage

The heart of the plan consists of seven best practices that were developed by the Washington State chapter of the American College of Emergency Physicians (ACEP), the Washington State Medical Association, and the Washington State Hospital Association (WHSA). "We spent considerable time discerning what we could do to reduce ED visits based upon the literature and also based upon what we see in our hospitals and EDs," explains Carol Wagner, the senior vice president of patient safety for the Washington State Hospital Association (WSHA) in Seattle, WA. "There is a strong commitment from the hospitals to design a better way of providing care."

Nathan Schlicher, MD, associate medical director at St. Joseph Medical Center in Tacoma, WA, and a spokesman for the Washington Chapter of ACEP, says that the state's emergency physicians are on board with the plan, and that the approach is moving the state in a "positive direction."

Some of the best practices will take time to fully implement, but hospitals had to indicate their willingness to comply by mid-June. The best practices include:

  • Adoption of an electronic information exchange system to share information about ED visits with other hospitals.
  • Education of patients about the appropriate use of the emergency department.
  • Dissemination of lists of patients enrolled in a Patient Review and Coordination Program (PRCP) so that frequent users can be identified when they come into the ED.
  • A process to contact a PRCP client's primary care physician when they come into the ED, and to make a follow-up appointment where appropriate.
  • Implementation of narcotic guidelines.
  • Physician enrollment in the state's Prescription Monitoring Program.
  • Designation of staff to review the state's utilization feedback reports and take appropriate action in response to the information contained in the feedback reports.

Primary care access is critical

While the electronic information exchange was fully functional by mid-June, Wagner explains that it will probably be October before all the hospital interfaces for the exchange are completed. Further, to help hospitals with the education requirements, WSHA has developed a brochure that lists what types of conditions should generally be treated in a primary care setting or an urgent care center, and when patients really should go to an ED. "We believe this brochure will be helpful for not only when patients wait in EDs, but also to help reinforce education that is being delivered by the provider," explains Wagner. "The hospitals are very committed to implementing the seven best practices, and to looking for ways that care can be provided in a high quality manner in the most cost-effective setting."

Wagner acknowledges that access to primary care is a complicated problem that requires more than patient education. In fact, WSHA reached out to health care experts in other states to find out what strategies can be helpful in linking frequent-utilizers to primary care, and one recommendation that kept coming up as being helpful is the use of call centers to help patients understand what level of care they need. "[Consequently], WSHA is meeting with each of the Medicaid plans in the state to encourage them to have a strong call center, and also to look at the scripting that is used in the call centers," explains Wagner.

It is not uncommon for call center staff to tell patients that if they are worried, they should visit the ED, but this messaging can be problematic, says Wagner. "There are times when such instructions are helpful, but there are other times when patients could [more appropriately] be instructed to get an earlier appointment with their PCP or to go to an urgent care center."

Community resources differ, so hospitals are using a variety of mechanisms to connect patients to appropriate care. "In some communities there is not enough primary care coverage, so there are clinics being developed and other strategies to try to find resources for these patients when they are not in the hospital," explains Wagner.

Wagner adds that one issue that will require additional solutions, beyond the best practices, is mental health. "Funding for mental health care in Washington state is one of the lowest in the nation, and yet these patients need help and assistance," she says. "When these needs go unattended, a lot of times these patients end up in our EDs. We don't have all the answers around mental health, so it is something we are going to have to continue working on going forward."

Schlicher agrees, noting in published reports that 85% of the high-ED-utilizing patients have concurrent mental illnesses that often go untreated.

Hospitals, EDs must show progress

While connecting patients to primary care is obviously critical to reducing overutilization of the ED, Wagner stresses that it is also important for EDs across the state to be able to share information. "Regardless of where patients go for their ED visits — particularly if they are needing to go to the ED frequently — there will be a consistent plan across hospitals, and also an understanding of how potentially that patient could be treated in a setting that is probably even more convenient," observes Wagner.

Lack of primary care isn't the only reason why patients overutilize EDs. Many patients frequent EDs to obtain access to narcotic drugs, explains Wagner. To address this group, as well as other patients who frequently utilize the ED, the Washington State Health Care Authority has established a Patient Review and Coordination Program (PRCP) to connect high-utilizing patients with a PCP and a hospital so that they can receive more coordinated care for their increased needs, adds Wagner.

The PRCP will provide needed support and resources so that narcotics guidelines, developed by the Washington Chapter of the American College of Emergency Physicians, can be carried out. "The WSHA and the Washington State Medical Association have supported this. It is a great way to insure that the strategy is implemented across EDs so that there is a consistent way to approach narcotic-seeking patients," says Wagner. "There are posters and there are good materials for the clinicians to work from."

At press time, the Washington State Health Care Authority was still in the process of finalizing utilization feedback forms that will include key metrics around such issues as narcotic prescribing, and ED utilization among PRCP patients. These reports are designed to provide hospitals with performance updates around the seven best practices as well as overall ED utilization. "The state is looking for a reduction in ED visits," says Wagner. "The hospitals and EDs in Washington State hope to be able to demonstrate that."

While no specific targets have been publicized, the Washington state Health Care Authority is projecting that the collaborative effort will save more than $30 million in health care costs. With such a short timeline, Wagner is hopeful that the state will be satisfied with progress. "I believe what the state is looking for is a trend in terms of a reduction in ED utilization," she says. "Everybody is committed to providing high quality patient care, and continued access at lower cost. We need a sustainable health care delivery system."

Sources

  • Nathan Schlicher, MD, Associate Medical Director, St. Joseph Medical Center, Tacoma, WA. E-mail: schlicnr@yahoo.com.
  • Carol Wagner, Senior Vice President of Patient Safety, Washington State Hospital Association, Seattle, WA. Phone: 206-577-1831.
  • Eric Wasserman, MD, FACEP, Chairman, Emergency Medicine Department, Newark Beth Israel Hospital in Newark, NJ. Phone: 973-926-7000.

New Jersey effort lowers non-emergent utilization at two sites, but findings suggest more changes needed

Hospitals in Washington state are, arguably, under the most intense pressure to bring down utilization of the ED for non-emergent needs. However, many states are working on this problem, and some solutions have emerged, although funding remains a concern.

For example, in New Jersey, interventions developed by the New Jersey Hospital Association's Health Research and Educational Trust, the state Department of Human Resources, and the New Jersey Primary Care Association, successfully decreased Medicaid recipients' inappropriate use of the ED by more than 20% in a demonstration project that focused on two emergency departments over two and a half years.

Called the Community Partnership for ED Express Care and Case Management, the effort used a $4.8 million grant from the Centers for Medicare and Medicaid Services (CMS) to beef up support services for patients who presented to the ED with non-emergent needs.

"The less acute and less sick patients were split off from the main population or sicker patients," explains Eric Wasserman, MD, FACEP, chairman of the Emergency Medicine Department at Newark Beth Israel Hospital in Newark, NJ, one of the two demonstration sites. The other site was Monmouth Medical Center in Long Branch, NJ.

Once these less acute patients were provided with appropriate care for their needs, ED staff took extra steps to make sure they had an appropriate follow-up appointment with their primary care provider (PCP), or if they had no PCP, then they immediately scheduled an appointment with a partnering federally qualified health center. In addition, ED staff took the time to educate patients about the importance of having a medical home for their primary care needs, and they explained what conditions should be dealt with in a primary care setting rather than an ED.

"We had dedicated nurse practitioners who were taking care of these patients, and not only managing their current medical problems, but also focusing on what some of the factors were that made them come to the ED for their given complaint," says Wasserman. "The majority of these patients (89%) were uninsured or on Medicaid."

For patients with additional social needs, case managers were on hand at both the hospitals and participating health centers to arrange for transportation to their medical appointments or to provide other support services. They also followed-up on these patients, making sure they received any needed referrals for specialty care, and that they actually showed up at these appointments. "The additional resources made all the difference," says Wasserman.

New incentives are needed

At the conclusion of the demonstration, analysts found that ED visits for primary care at the two sites decreased by 22% even though overall ED volume increase by 1%. In addition, the reduced ED utilization for primary care needs improved patient flow through the ED, reducing the average patient turnaround time by about 15%, according to a report from the New Jersey Hospital Association (NJHA).

Analysts also found that the peak day for primary care visits in the ED was Monday, and that the peak times for these visits was between 10 am and 1 pm. The timing is important because many experts suggest that the reason patients flock to the ED for non-emergent needs is because federally qualified health centers are closed. These findings suggest there are other reasons.

Indeed, according to the NJHA's report on the demonstration, when patients who presented to the ED with non-emergent problems were asked why they came to the ED, 21% said they thought that they needed emergency care, 20% said their doctor's office was not open, and 12% said their doctor was not available that day.

As a result of the demonstration, the NJHA and the partnering organizations have unveiled several recommendations, most of which will require more work or resources to be fully implemented. For example, they note the need for consumer outreach so that the public is better educated about when to appropriately use the ED, and they also state that federally qualified health centers should make their availability and the quality of their services known to all populations.

The report also emphasizes that incentives need to be created to encourage patients to use primary care settings when appropriate. It's a problem of both access and economics, according to Wasserman. "In urban areas you have a lack of PCPs and limited hours at that, so even though patients sub-triage themselves to EDs, I think they don't necessarily have places to go or the means to pay for care, so there is going to have to be this whole restructuring of the system so that patients are incentivized to go elsewhere and not to the ED," he explains. "A lot of PCPs and sub-specialty clinics ask for payment up front, and if patients can't do that, there is no incentive to go there."

Further, while the interventions developed during the demonstration were effective at reducing inappropriate ED utilization, the grant money is no longer available to pay for the extra support services. "Many people believe that a lot of money can be saved if you see patients in a less costly environment as long as they are receiving care that is appropriate to their needs," says Wasserman. "But it has been left up to the EDs to see everybody who shows up, to try and explain to them that their particular problem could have been handled in a different setting, and hope for the best."