Hospitals around the country are devising new strategies to increase ER efficiency and discourage consumers from seeking care in the ER when an alternative healthcare setting will do. Scottsdale Healthcare now posts waiting times for its three ERs on its Web site, with updates every 10 minutes. Other hospitals have begun to charge a premium for non-urgent ER visits. And last week, CMS awarded $50 million in grants to 20 states that have proposed programs to reduce use of hospital ER rooms by Medicaid beneficiaries for non-emergent reasons. The grants will fund alternative healthcare settings for individuals with non-emergent medical needs, particularly in rural and underserved areas and for those programs that work closely with community hospitals.
In the news last week, studies from New York and Oregon — two states not on the CMS grantee list — indicated that ER visits from their uninsured residents are on the rise and costing their hospitals money. A report by the United Hospital Fund found that while hospital ERs in New York City often provide routine care for the uninsured, the disparities were higher than expected. Among the 10 neighborhoods where residents visited the emergency room most often, nine were among those with the highest poverty and mortality rates, the report found. In Oregon, a study by Ohio Health and Science University found that visits to ERs by the uninsured and mentally ill are up 20 percent this year, which the researchers attributed to 2003 cuts to the Oregon Health Plan, Oregon's Medicaid expansion program.
ER redirection strategies proposed by CMS grantees represent some new thinking in this space that may inspire other organizations — and much of it originates in South Dakota. One project will deliver primary care to the schools via Sioux Falls' high school-based health center and to an Indian reservation via a mobile health clinic and targeted disease management efforts there. There's also the technology-based South Dakota Telehealth Urgent Care Clinic project. And psychiatric diversion tactics are addressed by Illinois, Rhode Island and others, who will partner with behavioral health providers to permit those clients to be seen in a non-emergent behavioral healthcare or primary care setting.
Other ER redirection ideas from CMS grantees cover ground that should improve the overall condition of primary care:
Developing primary care medical homes (proposed by nine of 20 grantees);
Opening new community health centers;
- Extending hours at existing clinics;
- Increasing reliance on APNs, case managers and patient advocates;
- Educating beneficiaries about appropriate ER use and new services;
- Wiring facilities for e-health data exchange.
Below are project highlights from CMS grantees:
Colorado, San Luis Valley Region:
Operational hours for a convenient care service will be specifically designed to provide primary care alternatives during hours when there is no other choice than the ED (nights and weekends), while also overlapping mid-afternoon hours with the highest known frequency of visits in the ED, providing 61 additional hours of operation per week. The proposed model is also intended to address interventions that correlate with decreased ED usage, including providing health education, teaching patients how to use the healthcare system, and offering counseling on social/emotional issues.
New Jersey Division of Medical Assistance and Health Services:
All patients who present to the ED will be triaged and receive medical screening by an advanced practice nurse (APN). Once a patient is determined to have non-emergency primary care needs, the APN will provide express primary care services and prescriptions, either as part of the triage/medical screening or immediately following. As part of discharge services for Medicaid/uninsured patients, the APN will set up the follow-up appointment with a primary care provider in the community, such as the participating FQHC.
During ED discharge, the APN will also educate express care patients on the appropriate site of care and the importance of using a medical home for primary care services and limiting ED visits to true emergency situations. Clinical information about specific patients’ use of ED for primary care needs will be shared with FQHCs and HMOs so they may take responsibility for their patients and provide more outreach/education.
Colorado, Pike Peak Region:
Will promote the concept of the medical home and offer real time referrals to alternative non-emergency care through the use of Outreach Case Managers.
Connecticut Department of Social Services:
Launching a My Health Direct web portal to facilitate access to primary care for Medicaid recipients by removing barriers patients face to obtaining primary care appointments and enhancing linkages between emergency departments and community-based primary care providers. Will offer appointment scheduling 24/7.
Georgia Department of Community Health:
Equipping more Georgians with medical homes.
Partnering with behavioral health providers so clients seeking non-emergent care may be seen in a non-emergent primary care and behavioral health settings.
Staffing two by advanced practice nurses and a patient navigator who will help link patients with primary care providers, mental health and/or other community services. One of the advanced practice nurses at each site will have a mental health background in order to assist in screening for underlying mental health concerns that may drive individuals to seek hospital emergency room services.
In phase one, FQHCs are beginning to work with their local community hospitals to identify strategies to divert non-acute and patients without a primary care provider to the FQHC for follow-up and ongoing care. In phase two, they'll get the technical tools to support this.
Michigan Department of Community Health:
Patients will be diverted to care at the FQHC through community marketing efforts intended to help them seek care appropriately when the ER is not needed, through hospital telephone triage and through direct referral of those who do come in to the emergency room.
Michigan, Hamilton Community Health Network:
Case Management Services for Medicaid patients identified as frequent utilizers of the ER for
non-emergent care and those patients who have identified chronic care conditions. Establish a primary care home for Medicaid patients who do not have an identified primary care provider.
North Carolina Department of Health and Human Services:
Will provide incentives and support to 40 large Community Care practices, which are willing to become alternative non-emergency providers (“advanced medical homes”) in the communities they serve, offering extended and alternative hours.
Will be done tracking the utilization patterns of the emergency room, confirming appropriate use and misuse of the ER, developing and launching an educational awareness outreach plan, and determining and implementing a cost-effective corrective action plan.
Oklahoma Health Care Authority:
Adding a Health Educator and two Community Health Workers (CHWs) to develop an Emergency Department Reduction Pathway and a Medical Home Pathway in conjunction with the University of Oklahoma’s Medical Center (OU), St. Anthony Hospital and Central Oklahoma Integrated Network Systems, Inc. (COINS). This is a four-week training to develop competencies in pathway development, healthcare system operations, social services, communication skills, motivational interviewing, health education and self-management of chronic diseases. CHCI will contract with OU College of Medicine to have resident physicians to provide medical services for additional 20 hours per week, thereby increasing access.
Pennsylvania Department of Public Welfare:
Will promote the medical home concept and launch a statewide campaign to educate Medicaid recipients on the appropriate use of ED services. UPMC Health Plan will establish alternate non-emergency providers to serve the target population.
Rhode Island Executive Office of Health and Human Services:
Project includes an ED psychiatric diversion project.
South Dakota Department of Social Services:
Will pilot a school-based health center in one of three public high schools in Sioux Falls. By providing convenient, alternative access to non-emergent health care, this program is intended to reduce the number of Sioux Falls high school students seeking non-emergent care in area emergency rooms.
The South Dakota Telehealth Urgent Care Clinic Pilot Project:
Will allow patients to receive local primary care, after hours, in their home clinic. Three pilot sites will be selected and will each have a nurse facilitate needed urgent care through advanced telehealth technology linked to an urgent care physician located in an urban community in the state. By providing telehealth consults, one provider is able to assist many remote sites with smaller volumes. Additional staffing is only needed for the RN to facilitate the visits.
Pine Ridge, South Dakota Chronic Care Clinic Access:
This project will increase access to non-emergency health care services for South Dakotans on the Pine Ridge Indian Reservation in Shannon and Todd Counties. Regional Health System will provide chronic disease management clinics for Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), Diabetes and Warfarin management.
South Dakota’s Pine Ridge Indian Reservation:
This project will provide medical homes to children and pregnant women on the Pine Ridge Reservation through a variety of innovative mechanisms. The geography of the reservation coupled with the stark poverty of the population creates a need to bring services to outlying communities via a Mobile Health Clinic. Medical homes will also be provided to children at schools located on the reservation, and the school clinic at Red Shirt will be operationalized to maximize access to regular primary care.
Tennessee Department of Finance and Administration:
Hardeman County Community Health Center will establish partnerships with other agencies including dental, mental health, translation, and transportation to ensure financial arrangements for patients needing such services.
Nashville Medical Home Connection:
Medical Home Connection will link hospital emergency room Medicaid/TennCare members in Nashville/Davidson County with alternate non-emergency primary care providers for their non-emergency care.