Health plans focus on inappropriate emergency department use
Health plans focus on inappropriate emergency department use
Interventions steer patients to appropriate levels of care
Faced with an increase in patients who seek care in the emergency departments for non-urgent conditions, health plans are looking for ways to reduce unnecessary visits to the emergency department and steer patients to more appropriate levels of care.
"We want patients to be treated at the right level of care and the right place. It's better for them and it's more cost-effective for the health plan when patients are treated in the appropriate level of care," says Deb Smyers, RN, BSN, senior director of program development for UPMC Health Plan, based in Pittsburgh, PA.
When patients use the emergency department for primary care, they don't have any continuity in care and conditions like elevated blood pressure that occur regularly may be overlooked if they come in for another complaint. In addition, seeing patients for non-emergencies sometimes ties up the clinical staff when patients come in with true emergencies.
Many patients who use the hospital as a primary care provider don't follow up with their primary care provider, even if they are instructed to do so, and don't receive the recommended preventive care, Smyers adds.
"We want people to visit the emergency department when they have a true emergency, but we know that they get better continuity in care when they see their primary provider," she says.
Making sure patients have a medical home is a key part of ensuring that members receive care in the appropriate setting, adds Anna Page, RN, director of utilization management for Passport Health Plan, a Medicaid health plan based in Louisville, KY. "We want them to see their primary care provider regularly for preventative care and call their physician office when they don't feel well," she adds.
Some patients use the emergency room for primary care because that's what their mothers and grandmothers did, she adds. Others may not have a primary care provider or they may have one in an inconvenient location or one they don't like, or the primary care office is closed when they get off work. Some patients go to the emergency department because they don't have transportation to their physician office but can utilize an ambulance for an emergency department visit, Page adds.
"We're trying to get a handle on why members go to the emergency department as opposed to the primary care provider or urgent care center," she says. Passport's ER coordinator calls patients who have used the emergency department during normal primary care office hours and educates them on more appropriate locations to receive care.
For some patients, coming to the emergency department is much easier than going to their primary care physician office, says John Lovelace, MS, MSIS, president of UPMC for You, the medical assistance program for UPMC Health Plan. "If they have to take a bus, they're likely to have a long journey, but they can call an ambulance that takes them right to their door. The emergency department waiting room is comfortable, the staff is nice, and often the wait is not as long as it would have been in a primary care setting," he adds.
UPMC has placed a patient navigator in the emergency department of a hospital within its health system that treats a lot of UPMC members. The health plan's care managers call patients who are frequent emergency department users and/or who have chronic illnesses and visit the emergency department for visits that could have been avoided if they managed their conditions better. In addition, the health plan sends a team of nurses and social workers to the homes of frequent users who are difficult to engage and have numerous psycho-social issues.
"When patients receive care in the appropriate setting, it's a win-win-win situation. The patient gets better care, the hospital emergency department can concentrate on treating patients with real emergencies, the health plan sees cost savings, and when patients go to their primary care providers, the physicians can do more effective clinical work," Lovelace says.
Faced with an increase in patients who seek care in the emergency departments for non-urgent conditions, health plans are looking for ways to reduce unnecessary visits to the emergency department and steer patients to more appropriate levels of care.Subscribe Now for Access
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