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Pediatric Emergency Department (ED) Case Management


Pediatric Emergency Department (ED) Case Management. Ramona Waltman, RN, BSN, CCM. Children s Healthcare of Atlanta – PowerPoint PPT presentation

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Title: Pediatric Emergency Department (ED) Case Management

Pediatric Emergency Department (ED) Case
  • Ramona Waltman, RN, BSN, CCM
  • Childrens Healthcare of Atlanta

Why do patients use the ED?
Childrens Healthcare of Atlanta Who Are We?
  • 3 Hospitals
  • 529 Beds
  • 24, 572 admissions for 136,769 bed days
  • 778,881 visits for 326,182 patients
  • 17 Neighborhood Locations
  • 5 Urgent Care Centers
  • Marcus Autism Center
  • 1 Primary Care Office

Facts and Figures
  • 200,000 yearly Emergency Department visits 550
    a day
  • 100,843 Urgent Care Visits
  • 46,551 Primary Care Physician Visits
  • Serviced all Georgia counties, 43 states and
    countries around the world

Childrens Healthcare of Atlanta is the
  • One of largest Clinical Pediatric Provider in
    United States
  • Largest Georgia Medicaid Provider
  • 10th private employer in Georgia with 7800 staff
  • Trauma Provider for pediatrics in Georgia
  • Pediatric Rehabilitation Services
  • Transplant Services
  • AFLAC (Hematology/Oncology Services)
  • Focus on Disease Management, Asthma and Diabetes

Transplantation Performed at Childrens
Healthcare of Atlanta
  • Liver, Kidney, Bone Marrow and Hearts
  • 475 Kidneys
  • 19 Livers, youngest and smallest patient weighing
    2 pounds
  • Only pediatric center in Georgia for heart
    transplants, performed 3 transplants in a 24 hour
    period, one of few centers for ABO incompatible
    blood types
  • 62 Bone Marrow Transplants and cures for 30
    patients with Sickle Cell Disease
  • http//careforceconnection/Departments/TransplantS

Strong 4 Life Program
  • Addressing childhood obesity jointly through
    efforts and partnering with community support and
    government agencies in Georgia
  • 40 of Georgias children are obese, making
    Georgia 2nd in the country for obesity in
  • Childrens Healthcare of Atlanta employees have
    lost 35,459 pounds with fitness opportunities

Why Childrens Healthcare of Atlanta is Crucial
to Georgia
  • 28 of Georgias total population are children
  • 52 of those children are enrolled in Medicaid or
    Georgias State Childrens Health Insurance
    Program (SCHIP) known as Peach Care
  • 300,000 of Georgias children are uninsured
  • Childrens Healthcare of Atlanta provided 90
    million in unreimbursed care in 2011

Where to go?
Georgia Medicaid
  • Traditional Medicaid manages children who are
    eligible for supplemental security disability
    income and children in foster care
  • The remainder of children enrolled in Georgias
    Medicaid program are enrolled in one of
    Medicaids care management organizations
  • Wellcare
  • Amerigroup
  • Peachstate
  • Another option is Peach Care, Georgias state
    child health insurance program. This option
    requires income eligibility and a monthly premium
    payment at a reduced rate for the families

Why use the Emergency Department instead of
Primary Care Providers?
  • Convenience
  • Decreased wait times Victims of our Own Success
  • Perception of Quality of Care
  • ED access to diagnostic tests not available at
    Primary Care Provider
  • Transportation barrier among families
  • Often one car family (mother not driver) or a
    neighbors car available
  • Financial Incentive
  • Co-pays established for Primary Care Provider
    visits but not Emergency Department visits by
    Care Management Organization for Medicaid patients

Georgia Medicaid
  • Traditional Medicaid manages catastrophic
    illnesses and children in foster care
  • Remainder of Children are enrolled in Medicaid
    care management organizations
  • Wellcare
  • Amerigroup
  • Peachstate
  • Nominal fee for coverage through Peach Care,
    which is Georgias state child health insurance

I am not feeling well, I vomiked twice! When
can I see you?
Patient Barriers to Primary Care Access
  • Perceived barriers when contacting Primary Care
    Providers (PCP)
  • Access to PCPs nurse advice line
  • If you feel you have an emergency hang up and
    call 911 or go to the nearest ED
  • If you want to talk to a nurse or physician,
    this call will be subject to a 15 charge. Any
    calls to the CHOA nurse advice line will also be
    subject to a 15 charge. (Call center Services
    must charge fees due to Stark Laws while most
    insurance companies have a 24hr free nurse advice
    line) 1
  • Limited availability same day and after hours
  • Compensation model from payers

1 Zaman Pediatrics After Hours Line 770-995-2946
Pediatric ED Case Manager Position and Scope of
  • SR Case Manager position started Jan 1, 2012
  • 1 FTE
  • Staffed 8am-5pm 5 days/week (rotates between 2
    main campuses)
  • 2500 ED CM referrals in the first 6 months

Pediatrics ED Case Manager Key Objectives
  • Identify and reduce patient access barriers that
    result in non-emergent ED visits
  • Target subset high utilizers
  • Work directly with 3 Medicaid care management
    organizations (CMO) ED Case Managers to address
    payer specific barriers to primary care
  • Support ED physicians to ensure adequate follow
    up for primary and specialty care
  • Coordinate referrals to Patient Financial
    Services to determine financial eligibility for
  • Partner with ED physician and nursing staff to
    identify risk factors and patient specific
    conditions leading to 72hr ED returns
  • Educate ED physicians on documentation of
    medically necessary admission criterias

Connecting Patients and Payers
  • 3 Medicaid Care Management Organizations in
  • Daily list of ED visits sent to payers
  • Initiated communication with hospital and CMOs
  • Identify any actionable barriers to care that
    result in ED visits?
  • Identified contact individuals at each payer
  • Target frequent ED users (6 visits/rolling
    calendar year)
  • Identify actionable items representing barriers
    to access resulting in repeated ED visits
  • Primary Care Physician assignment
  • Assigned to a specialist instead of Primary Care
  • Primary Care Physician assigned is great distance
    from home
  • Transportation barriers among patients and
  • Lack of access to free or low cost medical and
    dental clinics for uninsured pediatric patients
  • Provide community clinic lists

Case Manager Identifies Barriers to Outpatient
  • Neurology services
  • Reduction in physician providers on one campus
    from 7 to 4.5
  • Neurology practices are non-providers in Medicaid
    and CMO plans for outpatient visits
  • Orthopedic services
  • Resolved out of pocket expenditures for fracture
    patients covered by one CMO payer
  • Identifying barriers to follow-up care for
    uninsured, Medicaid pending and non-documented

Outpatient Follow-Up Barriers Finding a Solution
  • 2 new seizure clinics operationalized
  • Decreased time for new seizure follow up
    appointments from 2 months to 1 week
  • Clinic physicians provides Neurology Services
    for hospitalized patients
  • Partnered with Neuroscience Service Line
  • First Time Non Febrile Seizure Pathway
  • CM responsible for ED patient follow-up
  • Referral s of patient to Seizure Clinic

Primary Care Collaboration
  • Initiated meeting with Medical Director and staff
    of Primary Care
  • Established communication to identify Primary
    Care patients with high Emergency Department
  • Reported scheduling issues identified at Primary
  • Identified Primary Care patients who could
    benefit from Primary Care follow-up post
    Emergency Department visits
  • Reporting initiated to provide data for Primary
    Care patients treated in ED setting, being shared
    weekly to identify need for follow-up at Primary

Uninsured Patients Reducing the Financial Impact
  • Identified that uninsured patients (potentially
    eligible for assistance) receive limited follow
    up by our financial counseling team
  • ED charges lt 3,000/visit frequently routinely
    not recovered
  • Problem identified by ED Case Manager
  • Established a process to identify and refer
    patients to financial counseling
  • Single ED visit gt 3,000
  • 6 emergency department visits in 12 month period
  • Multiple siblings treated during same ED visit
  • Out of state Medicaid patients who have moved to
    Georgia and need to transition/apply for Georgia
  • Currently tracking financial success with a goal
    of recouping 10 ED charges on patients eligible
    for coverage

Future Goals for Tracking
  • Are there trends of unscheduled ED return visits
    that can help identify high risk conditions and
  • Bronchiolitis
  • Cellulitis
  • Track unscheduled 72hr ED return visits
    categorized by
  • Age of patient
  • Payer source
  • Diagnosis
  • Reason for return to ED

Admission Level of Care Getting it Right on the
Front End
  • Increasing pressure to justify medical necessity
    for short inpatient admissions
  • Insurance denials
  • RAC Audits
  • Significant difference in compensation between
    Inpatient vs. Observation Admissions
  • Educate physicians on documentation of medical
    necessity criteria for DRGs with 1-2 days LOS
  • Asthma
  • Pneumonia
  • Bronchiolitis
  • Acute Gastroenteritis

Pediatric ED Case Manager Tracking Performance
  • Patients with high utilization of ED services
    referred to each CMO
  • Document follow up from payer at 3 months
  • Assess impact in reducing non-emergent ED visits
  • Number of uninsured patients referred to
    financial counseling
  • Reimbursement received through retroactive
    Medicaid billing
  • Medical predictors by DRG for 72 ED return and
    subsequent readmission
  • Bronchiolitis (age, 02 saturation)
  • Cellulitis (age, presence of abscess, location
    infection, presence of fever)

Meeting The Case Management Need
  • Tracking patients who left without being seen
  • Tracking patients who leave against medical
  • Prevention of unnecessary ED visits
  • Expanding the coverage to second campus

Summary of Patients Receiving Benefits of ED
Case Management at Childrens Healthcare of
  • Patients needing specialty care follow up
  • Neurology
  • Orthopedics
  • Patients needing a better fit with their primary
    care physician
  • Patients covered by Care Management Organizations
    (CMO) who need coordination of care
  • Patients who are uninsured/non-documented and
    require continuation of care
  • Patients covered by out of state Medicaid
    programs who reside in Georgia and need to
    transition to Georgia Medicaid