nothing to disclose reducing the impact of low- acuity ed visits - ihi home...

Reducing the Impact of Low-Acuity ED Visits

Cambridge, MA

Presenter has

nothing to disclose

Kedar S. Mate, MD

November 1, 2016

Objectives

• Describe strategies for reducing the impact of low-acuity ED visits

• Understand how the creation and expansion of less costly, more

convenient, alternatives to ED visits can reduce diversions,

overcrowding, and waits and delays.

• Describe examples where there has been success in relocating ED

care to the right place, at the right time, for the right reason

Agenda

• Context – Policy Landscape

• Business case discussion

• Theory of change for reducing impact of low-

acuity ED visits

• Examples from the field

Overall ED Utilization in US

• 136.3 million visits (44.5 visits per 100 persons)

– 40.2 million injury related visits

• 16.2 million (11.9%) visits resulting in hospital

admission

• 2.1 million visits resulting in admission to critical

care unit

• 27% seen in less than 15 minutes

• 2.1% of visits resulting in transfer to different

hospital

National Hospital Ambulatory Medicare Care Survey: CDC

http://www.cdc.gov/nchs/fastats/emergency-department.htm

ED Utilization by Your States

Impact of ACA

• ED care and primary/preventive services are 2

of the 10 “essential benefits”

In theory, this may:

+ Increase use of emergency services

+ Increase primary & preventive services

- Leading to lower use of emergency services

Impact of ACA







↑

↑

?

Massachusetts

• Health care reform law in 2006 providing

coverage to nearly all residents

• Preventable ED visits reduced 5-8% for non-

urgent or primary care ED visits relative to other

states.(1)

• Between 2006-2010 ED visits and non-urgent

visits dropped 1.9 and 3.8% respectively.(2)

1. Miller, Sarah (June 2012). "The Effect of Insurance on Emergency Room Visits: An Analysis of the 2006 Massachusetts Health

Reform)"(PDF).

2. Long, Sharon K; Karen Stockley; Heather Dahlen (January 2012). "Massachusetts Health Reforms: Uninsurance Remains Low,

Self-Reported Health Status Improves As State Prepares To Tackle Costs“

Snapshot of Massachusetts

Impact of ACA







↑

↑

↓

Avoidable ED Visits

• Most studies classify between 30-50% of all ED visits as non-urgent and potentially avoidable (up to 67m visits)

• Up to $38b in wasteful spending (1-2)

• 71% of 6.5 million ED visits (2010) made by commercially insured patients were for causes that do not require immediate attention in the ED, or are preventable with proper outpatient care. (3)

1. Weinick R, Billings J, Thorpe J, Ambulatory care sensitive emergency department visits: a national perspective, Abstr

AcademyHealth Meet, 2003;20(abstr no. 8):525-526

2. Uscher-Pines, Lori, et al. "Deciding to visit the emergency department for non-urgent conditions: A systematic review of the

literature." The American journal of managed care 19.1 (2013): 47.

3 Truven Health Analytics (formerly the healthcare business of Thomson Reuters) J. Roderick, Inc. Brian Erni, 631-584-2200 \

Non-urgent and Avoidable ED use

Defining “low-acuity” by ESIDegree of

Acuity

Level of

Acuity

Patient Condition/Description

High LEVEL 1

EMERGENT

Patients in this category require immediate attention

with maximal utilization of resources to prevent loss

of life, limb, or eyesight.

LEVEL 2

URGENT

Patients in this category should be seen by a

physician because of high risk for rapid deterioration,

loss of life, limb, or eyesight if treatment or

interventions are delayed.

Medium LEVEL 3

ACUTE

Patients who develop a sudden illness or injury within

24-48 hours. Symptoms and risk factors for serious

disease do not indicate a likelihood of rapid

deterioration in the near future.

Low LEVEL 4

ROUTINE

Patients with chronic complaints, medical

maintenance, or medical conditions posing no threat

to loss of life, limb, or eyesight.

LEVEL 5

ROUTINE

Patients in this category are currently stable and

require no resources such as labs or x-ray.

Business Case

Business case for reducing low-acuity

visits works when…

• The health care system takes on financial risk

for patients (fully value-based or global

payment)

• Safety net (or similar) system serving primarily

uninsured and Medicaid patients

• Any system with a severe supply-demand

mismatch

Driver diagram

Reduce the impact of low-acuity ED visits

Prevent low-acuity patients from coming to the ED in the

first place

Change Primary Care

Urgent Care & Retail clinics

Community Paramedicine & others

Telemedicine

Financing strategies

Improve Management of

low-acuity patients who have come to

the ED

Non-acute care in ED (fast track, urgent care, observation)

Clinical pathways & standard orders

Transition from ED to home

Snapshot of Massachusetts

MA Health Policy Commission

Changing Primary Care

• After-hours telephone consultation: reduced

‘inappropriate ED visits’ from 41% to 8% (1)

• Extend practice hours: adding night and weekend

hours reduced ED visits 8% over 18 mths (2)

• Open access scheduling: offers same-day services

to patients

• Group visits/shared appointments: 2-year RCT with

chronic-ill geriatric pts found 17% decrease ED use

(3)

• Make primary care available on work-site

1. Franco SM, Mitchell CK, Buzon RM. Primary care physician access and gatekeeping: a key to reducing emergency department

use. Clin Pediatr (Phila). 1997 Feb;36(2):63-8.

2. Neighborhood Health Plan, Unpublished findings.

3. Coleman EA, Eilertsen TB, Kramer AM, Magid DJ, Beck A, Conner D. Reducing emergency visits in older adults with chronic

illness. A randomized, controlled trial of group visits. Eff Clin Pract. 2001 Mar-Apr;4(2):49-57.

Effects of Primary care changes

• Broaden Access to Primary Care Services through Medical and Health Homes– Community Care of North Carolina reduced ED visit

rate by 16% for asthma, total savings to Medicaid and CHIP of $135m

• Focus on Frequent ED Users – “Super Utilizers”– Ambulatory Clinic on Site at ED

– Hennepin County Medical Center’s ambulatory ICU clinic observed a 38% decrease in ED visits and 25% decrease in hospitalizations in year

– Medicaid Health Homes that leverage community interventions for super-utilizers

Source: Department of Health and Human Services, January 2014

Effects of Primary care changes

• Target needs of people with behavioral health

problems

– 12.5% of all ED visits are for BH needs across all

payers

• Current situation:

– Fragmented, subpar care for those suffering co-

morbid behavioral health issues

– Overcrowding, trouble allocating scarce ED resources

for all


And MA Health Policy Commission

Improve primary care for BH

• Medical homes for people with substance abuse

problems– WellPoint Health in Indiana decreased ED utilization by 72%

and decreased controlled substance prescriptions by 38%

• Housing and case management– In Illinois, patients in housing program decreased ED use by

24%

– In New York, mobile health clinics and case management

decreased ED use by 20%

– In Pennsylvania, patient navigators worked with patients with

severe mental illness and reported 59% reduction in ED use


Driver diagram



first place

Change Primary Care



Telemedicine




the ED




Urgent care & retail clinics

• # visits grew 4x between

07-09

• >90% of visits for 10

primary conditions

(sinusitis, URIs, UTI, HTN

immunizations etc)

• Same 10 conditions make

up 12% of ED visits

Mehrotra, Ateev, et al. "Retail clinics, primary care physicians, and emergency departments: a comparison of patients’ visits." Health

Affairs27.5 (2008): 1272-1282.

Mehrotra, Ateev, and Judith R. Lave. "Visits to retail clinics grew fourfold from 2007 to 2009, although their share of overall outpatient

visits remains low." Health Affairs 31.9 (2012): 2123-2129.

Urgent care & retail clinics

Retail clinics, primary care physicians, and emergency departments: a comparison of patients’ visits

A Mehrotra, MC Wang, JR Lave, JL Adams… - Health Affairs, 2008

Driver diagram



first place

Change Primary Care



Telemedicine




the ED




Community Paramedicine Model

• Primary healthcare extension

• Substitution

• Community coordination

Blacker, N., Pearson, L., & Walker, T. (2009). Redesigning paramedic models of care to meet rural and remote community needs.

The 10th National Rural Health Conference, Cairns, Australia, May 17-20, 2009.

Lapert, A, Morganti, K.G., Margolis, G.S., Wasserman, J. & Kellerman, A.L. (2013, December). Giving EMS flexibility in transporting

low-acuity patients could generate substantial Medicare savings. Health Affairs, 32(12). 2142-2148.

Community Paramedicine

• 911 Nurse Triage - Low acuity 911 callers referred to a

trained RN who helps patient find appropriate resources

for their medical issue.

– 37% of 4,422 low-acuity 911 callers re-directed away from ED;

~$1.9 million saved

• EMS “Loyalty” Program - Patients who use 911 15+

times in 90 days enrolled for EMS provided home visits,

home-based care.

– 302 patients with pre- & post- data show 51.8% lower ED visits,

462 hospital admissions avoided, ~$8.1 million saved

http://www.medstar911.org/mobile-healthcare-programs

Other latent opportunities…Jersey

Source: Emma Stanton, South London and

Maudsley NHS Foundation Trust

Jersey Post

Driver diagram



first place

Change Primary Care



Telemedicine




the ED




Telemedicine

• Immediate access to caregivers

• Mainly used to reach rural places with complex interventions (e.gtelestroke)

• 28% of all peds ED visits could have been avoided (1)

• Decreased ED use by CHF patients by 33% (2)

• 29% decrease in ED use by geriatric patients in cohort-controlled study of senior living centers (3)

1. https://www.urmc.rochester.edu/news/story/1978/telemedicine-could-eradicate-many-expensive-ed-visits.aspx

2. Lehmann, Craig A., Nancy Mintz, and Jean Marie Giacini. "Impact of telehealth on healthcare utilization by congestive heart failure

patients."Disease Management & Health Outcomes 14.3 (2006): 163-169.

3. Shah, Manish N., et al. "High-intensity telemedicine decreases emergency department use for ambulatory care sensitive

conditions by older adult senior living community residents." Journal of the American Medical Directors Association 16.12 (2015):

1077-1081.

BH & Telemedicine

Driver diagram



first place

Change Primary Care



Telemedicine




the ED




Financing Strategies (1)

• The strategy: Increase co-pay for ED visit; Maintain or lower co-pay for OP visit

• Findings:– Dose response (1)

– Increase ED co-pay $20-35; decrease visits 12%

– Increase ED co-pay $50-100; decrease visits 23%

• Limitations:– May deter patients from seeking needed care

1. Hsu J, Price M, Brand R, Ray GT, Fireman B, Newhouse JP, Selby JV. Cost-sharing for emergency care and unfavorable clinical

events: findings from the safety and financial ramifications of ED copayments study. Health Serv Res. 2006 Oct;41(5):1801-20.

2. Journal of Managed Care Medicine

3. Others include Lowe 2008, Lowe 2010, Mortensen 2010

Henry Ford HMO (2) 2004 2005-2006

Copayment $0 $10-40 $50 $75 $100-$150

Non-emergent ED use Baseline -11% -42% -51% -62%

Financing Strategies (2)

• The strategy: Financially incent or penalize PCPs by measured rates of avoidable ED utilization

• Findings:– Blue Care Network of Michigan HMO (217,298 members)

– PCPs in different risk sharing arrangements for ED utilization.

– Compared to low or no risk:– PCPs at “medium risk” – members’ ED use decreased 33 visits per

1000 pts

– PCPs at “higher risk” – members’ ED use decreased 51 visits per 1000 pts

• Limitations:– May deter physicians from prescribing needed care

Relationship between primary care physician financial risk and member emergency department use in commercial HMO population,

The American Journal of Managed Care, June 2006

Driver diagram



first place

Change Primary Care



Telemedicine




the ED




Zocchi, Mark S., Mark S. McClelland, and Jesse M. Pines. "Increasing Throughput: Results from a 42-Hospital Collaborative to

Improve Emergency Department Flow." The Joint Commission Journal on Quality and Patient Safety 41.12 (2015): 532-553.

Non-acute care in the ED

• Fast-track non-life threatening conditions

– Reduced waiting time by 51 min; LOS by 28 min;

LWBS 4%

• Provide urgent care in separate space

– In 2011/12 the NHS Institute developed ambulatory

care model in ED

– Converted emergency admissions into “same day”

emergency episodes

– Reduced avoidable admissions

1. Sanchez, Miquel, et al. "Effects of a fast-track area on emergency department performance." The Journal of emergency

medicine 31.1 (2006): 117-120.

2. National Health Service, Ambulatory Emergency Care: Delivering same day emergency service, 2011

Clinical

Status >>

Acute Care

Services

are

Needed for

Moderately

-Ill Older

Adults

Triage Moderately-ill Older Adults by:

• Diagnosis and Treatment Needed

• Payment for Home-based Acute Care Services

Enhanced Assessment:

• Specific Home-care Needs

• Patient / Family Caregiver Capabilities & Competencies

• Patient Preferences

Selection of Home-based Care Services

(Asset map of Home-based Acute Care Services)

Transition Older Adults from the ED to Home-based Acute Care Services

• FU Care Arranged

• Real-time Handover Communications

Activate Home-based Acute Care Services

Evaluate and Review Outcomes for the Entire Episode

(from ED to Home-based Acute Care to Discharge)

Transition of Older Adults from the ED

to Home-based Acute Care Services

Putting it together

Driver diagram



first place

Change Primary Care



Telemedicine




the ED




• Northeast's largest nonprofit independent multi-

specialty medical group.

• Serves 675,000 patients across eastern

Massachusetts

• Early pioneer of population health & ACO

models

Driver diagram



first place

Change Primary Care



Telemedicine




the ED




Atrius Health: Program components

• Most practice are at level 3 NCQA PCMH certification

• Largest out-patient Behavioral Health department among physician practices in the Massachusetts

• Population managers who provide outreach services to improve outcomes

• Case managers and care facilitators who are assigned to keep high risk patients out of the hospital when appropriate

• Clinical pharmacists who do academic detailing to lower drug costs in general and manage medication for specific patients

• 24 x 7 telephone access to advanced practice clinicians and weekend/holiday urgent care

• Strong IT interoperability with preferred hospital partners

• Advanced use of electronic medical record with sophisticated data warehouse and analytics

Atrius Health: Results

• Medicaid: 37% fewer Emergency Room visits

• Medicare Advantage: 12% fewer Emergency Room visits, 5% fewer SNF admits

• Commercial PPO: 25% fewer Emergency Room visits

• Commercial HMO: 8% fewer inpatient admits

• Since 2012, Washington State has grappled with

curbing overutilization in the ED

• Started partnership between Washington State

Hospital Association, WA College of Emergency

Physicians and WA Medical Association that led

to the ER is for Emergencies program

• Aims to reduce overutilization of the ED and to

address narcotic drug-seeking behaviors.

Successful Acute Care Payment Reform Requires Working With the Emergency Department, Health Affairs Blog, May 2015

http://www.wsha.org/quality-safety/projects/er-is-for-emergencies/

Driver diagram



first place

Change Primary Care



Telemedicine




the ED




Washington’s “ER is for Emergencies”

• The ER is for Emergencies interventions include:– Narcotics guidelines and prescription drug monitoring

– Educating patients about appropriate use of EDs

– Identifying frequent users of ED and prehospital care and creating care plans

– Feedback of information to hospitals

• In its first year, estimated results for state Medicaid include:– Savings of more than $34 million

– ED visits decreased by nearly 9.9%

– Low acuity visits decreased by 14.2%

– Rate of frequent visitors (5+ visits) dropped 10.7%

Successful Acute Care Payment Reform Requires Working With the Emergency Department, Health Affairs Blog, May 2015

http://www.wsha.org/quality-safety/projects/er-is-for-emergencies/

Driver diagram



first place

Change Primary Care



Telemedicine




the ED




Open questions

• Which elements of the driver diagram are you

working on?

• What are you working on that is missing from the

driver diagram?

• How are you making the business/value case for

reducing low-acuity visits?

Thank You!

Kedar S. Mate, MD

Chief Innovation & Education OfficerInstitute for Healthcare Improvement

20 University Road, 7th Floor

Cambridge, MA

Department of Medicine

Weill Cornell Medical College

[email protected]

@KedarMate

nothing to disclose reducing the impact of low- acuity ed visits - ihi home...

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