Emergency Physician, MultiCare Auburn Medical Center; Immediate Past Chair, Washington Chapter American College of Emergency Physicians CEO, Providence Centralia Hospital - PowerPoint PPT Presentation

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Emergency Physician, MultiCare Auburn Medical Center; Immediate Past Chair, Washington Chapter American College of Emergency Physicians CEO, Providence Centralia Hospital

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Title: Emergency Physician, MultiCare Auburn Medical Center; Immediate Past Chair, Washington Chapter American College of Emergency Physicians CEO, Providence Centralia Hospital


1
Emergency Physician, MultiCare Auburn Medical
Center Immediate Past Chair, Washington Chapter
American College of Emergency PhysiciansCEO,
Providence Centralia Hospital
Reducing Preventable Emergency Room
VisitsOctober 10, 2012
Stephen Anderson, MD Cindy Mayo, FACHE
2
Partnering for Change
  • Washington State Hospital Association
  • Washington State Medical Association
  • Washington Chapter of the American College of
    Emergency Physicians

3
Emergency Room Overuse It Is a Problem
4
Medicaid ER Use Is High
  • In the past year
  • About 40 of Medicaid clients visited an ER
  • About 18 of people with private insurance
    visited an ER
  • Contributing factors
  • Lack of primary care
  • Substance abuse
  • Mental health

5
State Approaches to Curbing ER Use
When What Impact Status
Original proposal 3-visit limit on unnecessary use Cuts payments to providers Won lawsuit policy abandoned
Revised proposal No-payment for unnecessary visits Cuts payment to providers Delayed by the Governor just prior to implementation
Current policy Adoption of best practices Improves care delivery and reliance on ER as source of care Passed in latest state budget
6
Ultimate Goal Reduce Trend





Current projected trend
Changing the trend
7
  • An Opportunity Patients, when possible, should
    be treated by their primary care provider for
    non-emergency conditions in order to promote
    consistent, quality care helping protect
    physician/hospital payments.
  • By June 15, 2012 hospitals must have implemented
    best practices on
  • Electronic health information
  • Patient education
  • High-user client information/identification
  • High-user client care plans
  • Narcotics prescriptions
  • Prescription monitoring
  • Use of feedback information
  • By January 1, 2013 hospitals must demonstrate
    reduction in low acuity visits
  • If unsuccessful, physicians and hospitals will
    suffer major cuts in Medicaid ER payments

8
Best Practices Just First Step
  • HCA will perform a preliminary fiscal analysis
    and report to the legislature by January 2013
  • Focus
  • Outlier hospitals with high rates of unnecessary
    visits
  • High ER visits by PRC clients
  • Low rates of treatment plans for PRC clients
  • High rates of opiate prescriptions

9
Emergency Department Reports
10
gt5 Visits - ED Visit Rate Per 1000 Medicaid
Clients
25
20
15
10
5
Data from HCA
0
11
Low Acuity ED Visit Rate Per 1000 Medicaid
Clients
25
20
15
10
5
Data from HCA
0
12
PRC ED Visit Rate Per 1000 Medicaid Clients
8
7
6
5
4
3
2
1
Data from HCA
0
13
Number of Visits per Assigned PRC Client
14

Percent of PRC Patients Seen with Treatment Plan
Rapid adoption of care plans even though many
hospitals just getting on EDIE.
15

Percent of Visits from Patients with 5 or More
Visits in the Last 12 Months
16

Percent of Completed Treatment Plans for PRC
Patients
17
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18
Scheduled Drug Average Units Per Prescription at
Hospital by Prescriber
19
Visits by PRC Clients with a Narcotic Prescription
20
Prescriber Trends
21
If Unsuccessful
  • Revert to the
  • no-payment policy.
  • 38 million in annual cuts!

22
Ongoing Oversight and Measurement
Emergency Department Workgroup
  • Health Care Authority
  • Washington State Chapter of the American College
    of Emergency Physicians (WA/ACEP)
  • Washington State Medical Association
  • Washington State Hospital Association

23
Emergency Department UtilizationOctober 2012
  • Cindy Mayo, FACHEProvidence Centralia Hospital

24
Providence Centralia Hospital
  • 128 bed acute care hospital located in Lewis
    County
  • On I-5 corridor approximately 30 miles south of
    Olympia
  • Lack of primary care providers accepting
    Medicaid, charity or self-pay
  • ED Volumes
  • 2008 32,669
  • 2009 35,273 Walk-in clinic opened Dec 2009
  • 2010 33,636
  • 2011 31,113
  • Unemployment 13-14 over past 3 years
  • Socio-economics, behavioral health and cultural
    issues
  • related to inappropriate ED utilization.

25
  • Baseline 2008 data 14,297 patients with ED
    visit triage level 4 or 5 (walk-in clinic, urgent
    care or dental)
  • Original data 25 charity and 24 Medicaid
  • ED Physicians asked us for assistance in
    resolving issue
  • Implementation of on campus FQHC walk-in clinic
    December 2009 (Valley View Health Center)
  • Establishment of referral and tracking of Dental
    patients

26
Original Team Participants
  • Name Position
  • John McCord, DPM (Retired) Community Board
    Member, PCH
  • Cindy Mayo, FACHE Chief Executive, PCH
  • Dennis Mesaros Chief Operating Officer, PCH
  • Jeanell Rasmussen Chief Nursing Officer/VP, PCH
  • Donna Frerich/Anne Schuchmann Emergency
    Department Director, PCH
  • Kristen West Executive Director, CHOICE Reg.
    Health Network
  • Kelly Delaney Patient Review Coordination,
    WA State DSHS
  • Robert McElhaney, MD Community Board Member, PCH
  • Paul Williams, MD Medical Staff President, PCH
    (2009)
  • Tricia Goldsby, DDS Private Practice Dentist
  • Isaac Pope, MD Community Pediatrician
  • Steve Clark Executive Director, Valley View
    Health Center
  • Gerda Barlow Director of Quality, PCH
  • Paula Godfrey, DO Lewis County Emergency
    Department Physicians
  • Linda DiRienzo Foundation Director, PCH
  • Justin Evander Finance, PCH
  • Sue Killilay Lewis County Behavioral Health
  • Donna Karvia Board Member, Valley View

27
Target Patient Population and Goals
  • Reduce Level 4 and 5 triage emergency visits by
    10 from 2008 baseline data
  • Reduce ED visits for dental issues by 10
  • Reduce ED patients with repeat/multiple visits
    for dental issues by 10
  • These patients have chronic diseases, behavioral
    health issues, drug seeking behaviors, dental
    issues and inability to establish primary care
    home

28
Implementation December 2009
  • Valley View Walk-In Clinic on hospital campus
    open 7 days a week, noon-10 pm
  • Advertised in local paper and local school system
  • Emergency department post discharge follow-up to
    Valley View Health Center, Valley View Walk-In
    Clinic and Valley View Dental Center
  • Dental referral began June 2009 (modified case
    management process)
  • Post acute care discharge referral to Valley View
    for follow-up visit
  • Walk-In Clinic opened December 2009
  • Walk-In Clinic space donated to Valley View by
    Providence Centralia Hospital (for first 2 years)

29

Goals Amount Goal Results
Reduce Level 4 and 5 triage Emergency Department visits (Baseline data 2008) 10 reduction 22 reduction
Reduce dental visits to Emergency Department (Baseline data 2008-5/31/2009) 10 reduction 45 reduction
Reduce patients with multiple Emergency Department visit for dental care (Baseline data 2008-5/31/2009) 10 reduction 20.5 reduction
30
2011 Data
31
2011 Data Continued
32
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33
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34
Identify Frequent ED Utilizers Develop Plan of
Care
  • ED Consistent Care Program (EDCCP)
  • Reps from CHOICE, Cascade Mental Health, STECK
    Clinic, Valley View, DSHS, PCH ED Leadership
  • Team meets 2nd Tuesday of the month to review
    referrals given by staff, LIPs, Molina or EDIE
  • ED Leadership meets one a month to review
    referrals and input Plans of Care which are then
    presented at the monthly meetings
  • Each person referred to EDCCP has a Plan of Care
    - Plans of Care are entered into EDIE
  • An informal letter is sent to the patient and a
    letter is sent to the PCP (if applicable)
    advising them of their patient involvement in the
    program
  • There are currently 125 patients in the PCH data
    base
  • Of note EDI tracking states there has been a 3
    visit reduction in this patient population

35
Patient Sample Letter
  •  
  • Providence Centralia Hospital Emergency
    Departments goal is to provide you with quality
    medical care. The Emergency Department
    Consistent Care Program is offered by the
    hospital and CHOICE Regional Health Network to
    help achieve this goal.
  •  
  •   Emergency departments are designed to provide
    evaluation, stabilization, and treatment of
    emergency conditions that threaten life or limb
    as well as acute illness or injury. Emergency
    departments are not designed to provide care for
    chronic, non-emergent conditions or non-urgent
    illness.
  •   
  • When you present to the emergency department at
    Providence Centralia, you will be evaluated by a
    physician, nurse practitioner, or physician
    assistant to determine if you have an emergency
    medical condition, or are in active labor. If you
    have an emergency medical condition, or are in
    active labor, you will be stabilized and treated.
  •  
  • If you do not have an emergency condition or do
    not require admission to the hospital, you will
    be referred back to your primary care provider to
    address chronic pain, routine medical problems
    and medication refills. Controlled medications
    will be given through the emergency department
    only if the medical screening examination
    indicates you have an emergency medical condition
    and controlled medications are necessary to treat
    it.
  •  
  • The best medical care for you is to have one
    provider manage your chronic pain, minor
    illnesses and medications.
  • This cannot be done with sporadic, episodic
    visits to multiple clinics and emergency
    departments. If you do not have a primary care
    provider, CHOICE Regional Health Network can
    assist you in finding one. CHOICE can also assist
    you with prescription assistance, Basic Food and
    other social or health services. You can contact
    CHOICE at (800) 981-2123, or (360) 493-4550.
  •  
  • Our records indicate you have visited Providence
    Centralia Hospital ____ times in the last year.
  • Through this program we will develop a plan of
    care for you while you are in the emergency
    department. We will contact your primary care
    provider about your plan of care and your use of
    the emergency department. We will also review the
    care and treatment you have received at other
    hospital emergency departments.
  •  
  • If you have questions about the process, or
    would like to have a Health Resources Coordinator
    help you, please contact CHOICE at (800)
    981-2123, or (360) 493-4550.
  • Through this program we hope to provide you with
    more coordinated and effective care.
  •    Sincerely,
  • Paula Godfrey, D.O. Physician Coordinator,
    Emergency Department Consistent Care Program

36
2012 FocusEducate All ED Patients Regarding
Appropriate Use of Emergency Department
  • ED Utilization Brochure Distributed to
  • 18 local MD practices, clinics, pediatrician and
    specialty offices (to reduce inappropriate office
    referrals to ED)
  • Chamber of Commerce United Way
  • Centralia College Red Cross
  • Lewis Co Food Bank Homeless Shelter
  • DSHS local offices WorkSource
  • Local media coverage via interview with KELA
    radio on 4/3/12
  • Attached brochure to be reviewed at ED Staff
    Meetings on 4/5 and 4/6 with distribution in the
    ED Discharge packets to begin in late April 2012
  • Where Should You Go for Care memo to be
    published in the Community Health Newsletter
    mailed to every household in Lewis and South
    Thurston counties the first week of May 2012

37
Insert Patient Brochure here
38
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39
Where should you go for care? Example
  • Where should you go for care?
  •  
  • When illness, accidents, and injuries happen,
    where should you go for care?
  • The answer depends on the seriousness and type
    of illness. Some options for health care include
    doctors offices and clinics, urgent care
    clinics, and hospital emergency rooms.
  • Providence Centralia Hospital has developed a
    new tool to help you make the best decision.
  • Doctors Office, Urgent Care Clinic or the
    Emergency Room A guide to help you choose the
    best place to go for health care brochures are
    now available at the hospital, local health care
    providers and community organizations throughout
    the area.
  • While you get the best care when you see your
    regular health care provider, the brochure gives
    common examples of when to call the doctors
    office when to visit an urgent care clinic and
    for life-threatening problems when to go to the
    Emergency Department.
  • Local urgent care and walk-in clinics are listed
    in the brochure, along with help-line phone
    numbers for many local insurance providers.
  • For those needing a regular health care
    provider, all three local Providence Medical
    Group clinics are accepting new patients, and
    some same-day appointments are available. Call
    the clinic in your area for more information
  • Chehalis Family Medicine 931 S. Market Blvd.
    360.767.6300
  • Rochester Family Medicine 18313 Paulson St. SW.
    360.273.8818
  • Centralia Internal Medicine 1010 South Scheuber
    Road  360.807.7966
  •  
  •  PROVIDENCE COMMUNITY HEALTH NEWSLETTER- TO BE
    MAILED THE FIRST WEEK OF MAY TO EVERY HOUSEHOLD
    IN SOUTH THURSTON AND LEWIS COUNTY (APPROXIMATELY
    40,000 HOUSEHOLDS). THIS IS THE TEXT TO GO TO
    DESGIN PRIOR TO PRINT.

40
Providence Centralia Hospital Pediatric After
Hours Clinic
  • Open 6pm-10pm daily
  • Staffed by local Pediatricians and ARNPS
  • Goal Reduce pediatric non-emergent utilization
    of Emergency Department
  • Volumes
  • 2011 6,869
  • 2012 (YTD annualized) - 7,762

41
  • Questions?
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