Posts Tagged ‘ER visits’

10 Things to Know About Reducing Avoidable ER Visits in 2014

September 18th, 2014 by Cheryl Miller

Despite expanded coverage available under the Affordable Care Act (ACA), the hospital emergency room (ER) remains a refuge for those unable to visit their primary care physician (PCP)— whether due to lack of access, insurance, or time, according to results from the latest Reducing Avoidable ER Visits Survey by the Healthcare Intelligence Network (HIN).

But more than half of respondents (65 percent) are confident CMS’s easing of telemedicine regulations (e.g. mandates for physician on-site hours) will help to reduce avoidable ER visits.

In the three years since HIN last administered this survey, health organizations have stepped up ER discharge follow-up efforts. Almost one-third of respondents (31 percent) in 2014 say they contact patients within 24 hours of their ER visit, versus 22 percent of respondents in 2011 who made provider appointments before discharge, and 18 percent who conducted phone follow-ups within two days of a visit.

Here are more metrics derived from the 2014 Reducing Avoidable ER Visits Survey:

  • Staffing solutions to reduce avoidable ER visits have changed: case managers, social workers and disease-specific care coordinators are increasingly utilized in the ED, replacing health educators, coaches, and nurse-only advice lines used in 2011.
  • The challenge of redirecting non-emergent patients, while still a primary barrier, decreased in priority from 29 percent in 2011 to 18 percent in 2014.
  • Insufficient care access remains a challenge, growing from 16 to 21 percent in 2014, along with PCP collaboration, which was still among the top three challenges, but decreased from 24 percent in 2011 to 18 percent in 2014.
  • The prevalence of programs to reduce avoidable ED usage remained relatively stable from 2011 to 2014, with nearly three quarters of respondents reporting such initiatives.
  • Among populations reported to generate the majority of avoidable ED visits, ER use by dual eligibles increased five-fold in the last four years, from 2 to 11 percent, while other populations — high utilizers, Medicare and Medicaid — remained roughly the same.
  • Chronic disease replaced pain management as the most frequently presented problem, at 54 percent.
  • Education and risk-based telephonic outreach are the top two patient-centered strategies used to reduce avoidable ER visits in 2014.
  • Behavioral health issues and privacy are considered two top legal and compliance obstacles in reducing avoidable ER visits, respondents say.

Source: 2014 Healthcare Benchmarks: Reducing Avoidable ER Visits

Stratifying High-Risk Patients


2014 Healthcare Benchmarks: Reducing Avoidable ER Visits
delivers actionable metrics from 125 healthcare organizations on their efforts to foster appropriate use of hospital ER departments. Enhanced with more than 50 easy-to-follow graphs and tables, this third edition of comprehensive data points presents year-over-year trends and best practices for engaging ER and hospital staff, primary care physicians, community providers and patients in reducing avoidable ED utilization.

4 Population Health Management Tools to Identify At-Risk Patients

February 15th, 2013 by Jessica Fornarotto

Our EPIC platform at Bon Secours Health System consists of different tools that our nurse navigators can use to identify at-risk patients, for instance the ability to create registries, states Robert Fortini, vice president and chief clinical officer at Bon Secours Health System. Bon Secours uses four main tools to help better manage the health of its population, including a tool that identifies barriers and non-adherence, as well as a risk calculator that measures frequent ER visits.

Inside of our EPIC platform, the documentation tool or encounter type that is created by using our discharge registry falls into one of four categories. It’s either a post-hospital admission, a post-emergency department visit, it could be for ongoing case management and the referral can come from any direction — the PCP, a managed care partner, or hospital case management. Then, if someone falls into a place where they’re at a gap in care, we use a number of different tools to identify those gaps in care.

To illustrate the documentation tool, take a patient who’s been admitted to the hospital, has spent some time there, and has been diagnosed with congestive heart failure (CHF). Everybody is focused on CHF these days because of value-based purchasing. And everyone is trying very hard to improve 30-day readmission rates now that there’s a penalty associated from that Medicare reimbursement.

We’re using a tool that allows our nurse navigators to stage the degree of heart failure. From within the documentation’s work space, we can launch the ‘Yale tool,’ which allows us to establish what stage of heart failure that patient is in; class one, class two, class three, class four. Then, a set of algorithms are launched based on these stages’ failure and we will then manage the patient according to those algorithms.

If a patient falls into a class four category, for example, we may bring them in the next day or that same day for an appointment, rather than wait five or seven days because they’re at more risk. We may also make daily phone calls or interventions; we may network in the home health and make sure that they have scales for weight management and assessment of heart failure status. All of those interventions will be driven by the class of heart failure that patient falls into.

The second tool that we use is a workflow around ejection fractions. Depending on the patient’s ejection fraction, we will define specific interventions that the nurse navigator will follow.

We have a third tool that’s part of the encounter type in the EPIC where we identify barriers and non-adherence. We look at several elements: Are there communication preferences that the patient requires in order to be clearly communicated with? Is there any cognitive impairment? Are financials a barrier? What are their utilities at home? What’s their learning style?

Each of these categories launches another subset or agenda that we can document in detail; specifically on what obstacles exist for that patient and then what goals we should be setting to breach those obstacles.

Finally, we have a risk calculator that’s specific to frequent ER visits. Using this risk calculator, we enter length of stay (LOS) in the hospital, acuity, comorbidities and the number of ED visits in the last six months. That will then generate a risk index. If that risk index is 11 or greater, that person is considered in a higher risk category and that will drive interventions that are more intensive; daily calls, being brought in sooner, maybe the implementation of a dosage titration, an algorithm around diuretic management for weight in a heart failure patient, etc.

Q&A: How Clinical Integration Creates Framework for Value-Based Payment Contract

August 8th, 2012 by Jessica Fornarotto

Advocate Physician Partners is proud of its infrastructure of success in shared savings, built on a foundation of clinical integration.

“To describe how valuable our clinical integration program is at Advocate Physician Partners, two areas need to be highlighted,” says Dr. Carrie Nelson, medical director for special projects with Advocate Physician Partners (APP).

Dr. Carrie Nelson, Medical Director for Special Projects


Prior to her presentation on Bending the Cost Curve with a Commercial Value-Based Payment Contract: A Case Study from Advocate Physician Partners, Dr. Nelson discussed in depth APP’s clinical integration program that helped to set the framework for their value-based payment contract with Blue Cross Blue Shield of Illinois (BCBSIL). This payor-provider agreement has reduced inpatient admissions and ER visits, and has bent the cost curve after its first year of implementation. APP’s clinical integration program is described in detail in
Case Study in Clinical Integration: The Advocate Physician Partners Experience.

HIN: How has APP’s clinical integration of more than 4,000 physicians and 10 hospitals over the last few years helped to lay the groundwork for your value-based payment contract?

(Dr. Carrie Nelson): We feel very fortunate that we have a strong clinical integration program in place. It has created a strong foundation for the work that we’re doing with shared savings. There are two major areas that demonstrate how valuable that foundation has been to us.

First, it is a culture of delivering that value that we have established here over the last eight years or so since we’ve been deeply involved in this clinical integration program. That has been a tremendous spirit to build upon with movement toward shared savings and value-based contracting. Physicians in our network have a strong understanding of the importance of delivering that value and achieving quality metrics and not just a fee-for-service volume-based approach to care.

The second would be the framework that it has laid for us in how we can continue to incentivize the physicians to achieve the goals associated with shared savings. We have been able to build a number of our key priorities into the clinical integration program, such as decreasing ER utilization, length of stay, and admissions for ambulatory care-sensitive conditions. Many of those things have rolled into our clinical integration program and have helped physicians to be energized to help achieve these shared goals.

We feel very fortunate that we had this program in place in many cases before it was truly rewarded. It has also provided this cultural basis and framework for building upon the successes that we’ve already seen. The last thing to remember is this: all that needs to be accomplished in shared savings can be overwhelming. Clinical integration and the measurements that we’ve been involved in for many years are some of those things.

It’s nice to be able to focus on some alternative areas to show our infrastructure of success in shared savings, instead of having to focus explicitly on just the measures that are brought along.