Multi-pronged approach targets ED use
Multi-pronged approach targets ED use
Initiative includes navigator, home visits
UPMC Health Plan in Pittsburgh, PA, takes a three-pronged approach to reducing unnecessary emergency department visits that includes outreach calls from care managers, stationing a patient navigator in an emergency department that serves a large UPMC population, and home visits by a nurse/social worker team for patients who need extra help in managing their healthcare.
Every day, the health plan receives a list of patients who have been in the emergency department the day before from hospitals that are part of the UMPC integrated delivery system and who see the majority of the health plan's members.
"We are getting real-time information on emergency department visits and use that to determine the people who will receive interventions. We get in on the front end, rather than waiting for claims which could take months," says Deb Smyers, RN, BSN, senior director of program development for the health plan.
The program targets Medicaid members who have been to the emergency department seven or more times in a 12-month period and patients enrolled in other UPMC Health Plan products who have visited the emergency department three or more times. The health plan also intervenes with patients with chronic conditions that could avoid emergency department visits if they managed their conditions well. Diabetes, asthma, chronic obstructive pulmonary disorder, heart failure, migraines, and low back pain are among the targeted conditions.
The health plan's care managers, either RNs or social workers, make outreach calls to members with excessive emergency department use, educate them on more appropriate levels of care, and encourage them to see their primary care provider regularly. They ask about barriers such as transportation and ask if they have been getting their prescriptions filled and are taking them as directed. They fax information to the primary care provider about the member's emergency department use and whatever care management or disease management interventions they are receiving.
The care coordinators educate the patients on alternatives to the emergency department, including urgent care clinics and their primary care provider and give them the hours they are open. "We encourage them to talk to their primary care provider if they are not feeling well and find out the doctor's recommendation of what to do," she says.
They discuss symptom management with patients with chronic conditions and, if appropriate, enroll them in a disease management program. For instance, when members have asthma, they teach them the triggers that indicate they should take their controller medicine along with the reliever medicine. "If they can identify symptoms and signs earlier and know what to do, they can avoid the emergency department," she says. In appropriate situations, they follow up with the patients again and help them manage the conditions that brought them to the emergency department.
The intervention has resulted in the reduction of 176 emergency department visits per quarter among members covered by all UPMC Health Plan products and a savings of $17 per member per month.
The health plan has placed a patient navigator in the emergency department at UPMC McKeesport in McKeesport, PA, a community hospital that treats a high volume of UPMC members and is the only hospital readily available to patients in that community. The navigator, who is a patient care technician who is attending nursing school at night, covers the emergency department from 8:30 a.m. to 5 p.m. weekdays because the health plan determined that is when the highest volume of unnecessary emergency department visits occurs.
"This hospital treats a high volume of our patients and is the only hospital available to patients in that community," says John Lovelace, MS, MSIS, president of UPMC for You. "The majority of patients they see are Medicaid or Medicare beneficiaries or those who have no insurance."
After patients are triaged, the hospital staff refer those with minor ailments to the navigator. The navigator sees any patient, regardless of insurance, who is using the emergency department inappropriately. The navigator finds out the reason the patients came to the emergency department instead of seeing their primary care physicians, educates them on seeking care in the appropriate setting, and helps them make a follow-up appointment with their primary care provider.
In some cases, the navigator helps patients identify their primary care provider or helps them make a connection.
The health plan began the program three years ago using funds from a grant from the Centers for Medicare & Medicaid Services through the Pennsylvania Department of Public Welfare to cut down on unnecessary emergency care for Medicaid recipients. Although the grant has been completed, the program is continuing. "We're sharing the cost of the navigator with the hospital because we have a mutual interest," Lovelace says. "It doesn't help them to have low-acuity patients in the emergency department, either."
The health plan has publicized the emergency department navigator program and enhanced primary care access on billboards in the community, on television spots, and in mailings to members.
The patient navigator has had contact with more than 6,000 patients, and about 5,000 patients have seen either the nurse practitioner or the primary care provider. Patients seeing the navigator keep their primary care appointments 80% to 90% of the time.
With this initiative, the health plan has seen a reduction in emergency department visits in addition to an increase in primary care sick visits.
UPMC Health Plan in Pittsburgh, PA, takes a three-pronged approach to reducing unnecessary emergency department visits that includes outreach calls from care managers, stationing a patient navigator in an emergency department that serves a large UPMC population, and home visits by a nurse/social worker team for patients who need extra help in managing their healthcare.Subscribe Now for Access
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