Avoiding Low-Acuity Emergency Room Visits:A Toolkit for Practices

This work was funded by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services’ Transforming Clinical Practice Initiates, under grant number 1CMS331549-03-00. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

Copyright © 2019 by Vanderbilt University Medical Center01

This is a collection of resources designed to help you and your practice reduce

avoidable emergency department visits. We are providing you with graphics to give to

your patients and hang in your practice, a patient questionnaire to assess their use of

the emergency department, and a way to track your practice’s progress.

Contents:

1. Plan

2. Do

3. Study

4. Act

5. Library of materials

This work was funded by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services’ Transforming Clinical Practice Initiates, under grant number 1CMS331549-03-00. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

Copyright © 2019 by Vanderbilt University Medical Center02

We are providing this information to you in the framework of what’s called

a Plan-Do-Study-Act cycle (PDSA). A PDSA cycle is a continuous quality

improvement tool that is commonly used to implement, document, and

test change within organizations. This PDSA tool has been designed for the

implementation of an Emergency Department Toolkit to reduce avoidable

emergency department visits with increased education, awareness, and

measurement of data. PDSA Cycles are a concept that originates from IHI

and quality improvement literature. For more information, please visit

IHI How to Improve and the Understand Data Powerpack for additional

information.

This work was funded by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services’ Transforming Clinical Practice Initiates, under grant number 1CMS331549-03-00. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

Copyright © 2019 by Vanderbilt University Medical Center03

Institute for Healthcare Improvement. (n.d.). How to Improve. Retrieved from http://www.ihi.org/resource/Pages/HowtoImprove/default.aspx

Why should you reduce ED visits?Low-Acuity Non-Emergent (LANE) visits refer to visits where the delay of several hours

would not increase the likelihood of an adverse outcome. Sometimes referred to as

preventable, inappropriate, non-emergent, or ambulatory-care sensitive. This

definition excludes new patients.

As shown below, 25% of ED visits are low-acuity and non-emergent.

On average, an ER visits costs 7x more than receiving care for the same reason in a doctor’s office or clinic.

This work was funded by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services’ Transforming Clinical Practice Initiates, under grant number 1CMS331549-03-00. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

Copyright © 2019 by Vanderbilt University Medical Center

% Of Daily ED Visit Types

Non-LANE

LANE

LANE Measurement Definition

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Plan

To begin the PDSA cycle, start by:

1. Reading through the contents of this toolkit to understand why and how it is

important to reduce avoidable ED visits.

2. Consider the size and layout of your practice to decide where you will you place

and hand out graphics [Placemat (A) and Where Should You Go (B) graphics].

3. Meet with your practice staff to discuss your patient population and patient flow

to decide how and when to administer Patient Questionnaire (C), as well as the

protocol for collecting data with the Data Tracking Spreadsheet (D).

4. Decide on a regular cadence for data progress review.

This work was funded by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services’ Transforming Clinical Practice Initiates, under grant number 1CMS331549-03-00. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

Copyright © 2019 by Vanderbilt University Medical Center05

DoNow that you have a plan, you can begin to implement the training and educational tools

we have provided.

Placemat (A)

How can this be used?

• Enlarge and hang Placemat (A) in practice locations such as in the lobby or break

room where providers can easily view.

• As an ongoing quality education tool in monthly QI meetings.

• In PowerPoint presentations for training on avoidable ED visits.

Data Tracking Spreadsheet (D)

How can this be used?

• Collect data by asking every patient if they have been to the ED. If “yes,” collect

additional data by using the questions in the Patient Questionnaire (C).

• Based on data collected in the Patient Questionnaire (C). Provider will make theclinical decision on if the visit was an Ambulatory Sensitive Condition (ASC)*.

• Data collection process can be collected at check-in or during the appointmentby the MA, Nurse, or Provider

Where Should You Go? (B) graphics

How can this be used?

• Given to all patients who have been to the ER since their last visit to the clinic.

• Given to patients who are enrolled in a care management program.

• Displayed within the practice.

• Used on practice website to increase education appropriate ED and urgent care

visits.

This work was funded by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services’ Transforming Clinical Practice Initiates, under grant number 1CMS331549-03-00. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

Copyright © 2019 by Vanderbilt University Medical Center06

*Ambulatory sensitive conditions (ASCs) are those conditions for which an emergency department visit or hospital admission could be prevented by interventions in primary care settings. Purdy, S., Griffin, T., Salisbury, C., & Sharp, D. (2009, February). Ambulatory care sensitive conditions: terminology and disease coding need to be more specific to aid policy makers and clinicians. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/19144363

Placemat (A)

Tools to use:

Where Should You Go (B)

Data Tracking Spreadsheet (D)

This work was funded by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services’ Transforming Clinical Practice Initiates, under grant number 1CMS331549-03-00. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

Copyright © 2019 by Vanderbilt University Medical Center07

Patient Questionnaire (C)

StudyNext your clinic should select its own reviewing period and should review data collection

regularly.

How is this done?

• Aggregate data from Data Tracking Spreadsheet (D) and use the graphing

function to determine whether trend is moving up or down.

• Remember that ED use will vary seasonally (higher use occurs in the winter), so a

true analysis is one period in time compared to the same period in time next year

after an intervention has been in place.

• Report and discuss findings transparently with practice at QI meeting.

• Discuss any interventions that have been used for reducing this measure, as well

as any challenges or barriers.

This work was funded by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services’ Transforming Clinical Practice Initiates, under grant number 1CMS331549-03-00. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

Copyright © 2019 by Vanderbilt University Medical Center

Data Tracking Spreadsheet (D)

Tools to use:

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ActAfter your review cycle, evaluate the percentage of avoidable ED visits and decide next

steps, based on if the trend is...

• Declining: consider building ED patient survey in EMR to simplify data collection

and analysis.

• Increasing or non-declining: Begin new PDSA cycle using the Practice Assessment

(E) to identify gaps in process and practice work flow.

This work was funded by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services’ Transforming Clinical Practice Initiates, under grant number 1CMS331549-03-00. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

Copyright © 2019 by Vanderbilt University Medical Center

Practice Assessment (E)

Tools to use:

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LibraryHere are all the tools and graphics to utilize during the PDSA cycle. The Data Tracking

Spreadsheet (D) can be found as a separate file.

Placemat (A) has two different formats—V.I and V.II. Both versions include the same

educational information, but have different design focus. The concept difference

between the two formats are as follows:

• V.I is an academic version of the placemat designed for use in internal educational

materials.

• V.II is an infographic version of the placemat designed for internal and external

marketing.

Each practice has the option to use either or both versions.

Click on any of the graphics, and then right click them to save them as images. You can

insert them into presentation slides or use on your website.

This work was funded by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services’ Transforming Clinical Practice Initiates, under grant number 1CMS331549-03-00. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

Copyright © 2019 by Vanderbilt University Medical Center10

This work was funded by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services’ Transforming Clinical Practice Initiates, under grant number 1CMS331549-03-00. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

Copyright © 2019 by Vanderbilt University Medical Center

A. Placemat V.I

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This work was funded by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services’ Transforming Clinical Practice Initiates, under grant number 1CMS331549-03-00. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

Copyright © 2019 by Vanderbilt University Medical Center

A. Placemat V.II

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This work was funded by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services’ Transforming Clinical Practice Initiates, under grant number 1CMS331549-03-00. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

Copyright © 2019 by Vanderbilt University Medical Center

B. Where Should You Go

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This work was funded by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services’ Transforming Clinical Practice Initiates, under grant number 1CMS331549-03-00. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

Copyright © 2019 by Vanderbilt University Medical Center

B. Where Should You Go

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C. Patient Questionnaire

This work was funded by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services’ Transforming Clinical Practice Initiates, under grant number 1CMS331549-03-00. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

Copyright © 2019 by Vanderbilt University Medical Center15

This work was funded by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services’ Transforming Clinical Practice Initiates, under grant number 1CMS331549-03-00. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

Copyright © 2019 by Vanderbilt University Medical Center

D. Data Tracking SpreadsheetThe Data Tracking Spreadsheet has been provided as a separate Excel™ file.

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E. Practice Assessment

This work was funded by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services’ Transforming Clinical Practice Initiates, under grant number 1CMS331549-03-00. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

Copyright © 2019 by Vanderbilt University Medical Center17

This work was funded by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services’ Transforming Clinical Practice Initiates, under grant number 1CMS331549-03-00. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

Copyright © 2019 by Vanderbilt University Medical Center

www.midsouthptn.com

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For additional tools and resources for reducing Unnecessary Emerency Department (ED) visits and hospital utilization, please review the Extended ED

Toolkit.

These materials were designed to improve educational interactions between healthcare providers and their patients. These materials are intended only for use by qualified health professionals in conjunction with their patients. Professionals opting to use these materials take responsibility for any liability issues related to their use. Specific recommendations to patients by providers may vary from what

is included in these materials.