Tackling 5 Care Barriers That Boost ER Use by Medicaid Patients

Tuesday, March 20th, 2012
This post was written by Patricia Donovan

Facing five specific barriers to timely primary care, Medicaid beneficiaries are twice as likely to visit the ER as their insured counterparts, according to a study published online in the Annals of Emergency Medicine.

The study cited five factors that hinder Medicaid patients’ access to primary care:

  • Inability to get through on the telephone;
  • Inability to obtain appointment soon enough;
  • Long waits in the physician’s office;
  • Limited clinic hours; and

  • Lack of transportation.

Twice as many people insured by Medicaid as by private insurance report these barriers to primary care, reported the researchers. More than one-third (39.6 percent) of Medicaid patients visited the ER within the last year versus 17.7 percent of privately insured patients.

A few years ago, Ohio ED use was nearing crisis proportions. ED utilization overall in Ohio was almost 30 percent higher than the national average, according to a 2008 data from the American Hospital Association, and about two-thirds of the utilization in Ohio EDs by Medicaid beneficiaries was considered non-emergent, PCP treatable and avoidable.

There sprung up a collaborative effort among five regions of Ohio to target the key reasons for avoidable ER visits among Medicaid beneficiaries and roll out test interventions in a rapid cycle quality improvement approach.

One intervention to reduce the number of upper respiratory infections (URIs) in children presenting in Ohio emergency rooms tackled some of the care access barriers that frustrate Medicaid patients. Its four-pronged intervention encompasses patient education, a nurse advice line, the engagement of primary care providers (PCPs) and health coach follow-up.

Ohio used a rapid cycle, quality improvement approach to reduce these visits, explains Mina Chang, Ph.D., chief, health services research and program development section of the Bureau of Health Services Research for the Ohio Department of Job & Family Services.

“Our program starts with a very upstream preventive intervention that provides patients alternative resources through a 24/7-nurse line,” explains Dr. Chang.

“The second leg of this intervention is that when patients or parents call into the nurse line, they will be able to get triage for their sick call for the sick kids.

“In this test intervention, a group of participating PCPs will make same day or next day appointments available. The triage nurse can refer those patients to those providers.”

The final leg of this testing intervention, she explains, is follow-up with parents by managed care health coaches to assess the effectiveness of an educational toolkit Ohio developed and the awareness of the parents of the 24/7 nurse line, as well as to conduct any follow-up that members might need.

Dr. Chang shares the preliminary results:

“After we sent out our kits, we followed up within two weeks. Approximately 231 kits were mailed to the families. We were successful in following up with half of those families; we were very impressed with that follow-up rate. If you have experience with the Medicaid population, typically they are very transient, so the follow-up rate is very low.

“Toolkit items that drew the most attention from the parents are the hand sanitizers, thermometers, tissues, medicine spoon, and a refrigerator magnet that included all the health points and nurse line numbers. Unfortunately, the printed material that we spent a lot of time working on, such as facts about colds, a letter from the PCP and some key phone numbers were not drawing a lot of attention from those parents at the time of follow-up.

“We also found that approximately half of those respondents had experience using the nurse line. And almost 98 percent are likely to use it again.”

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3 Responses to “Tackling 5 Care Barriers That Boost ER Use by Medicaid Patients”

  1. Brian Rike says:

    I didn’t know that nurse lines said anything other then go to the ER these days. They implemented a program of home health nursing type in Camden New Jersey and saved almost half the first year. Most of it looked like they targeted the high users of ER and see them at their house before letting them go to the ER. Most of the visits were managed at home and safely.

  2. Melanie Matthews says:

    We’ve heard many case studies of health plans that are using the nurse advice line to reduce avoidable ER use by pointing them to alternative sources of care, such as an urgent care center, or if appropriate by providing a care plan that would help to manage symptoms until a doctor’s appointment could be attained.

    Dr. Jeffrey Brenner’s work in Camden, N.J., highlighted in this article in the New Yorker:
    http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande provides amazing insight into how data analysis can truly transform care access and delivery and the possible reductions in healthcare spend.

  3. Brian Peters, MD says:

    For rural hospitals in Arizona pretty much accross the board the nurses in the emergency department when answering such calls are required by the hospital administration to say “we cannot give medical advice over the phone. If you feel you have a medical emergency you can come to the emergency department”. My impression that this mandate from administrators is based on liability concerns.