UPMC members who treat the ER as a primary care provider can expect a home visit from the health plan's community teams of nurses and social workers. Community teams visit these members at home to perform assessments and care management.
That's one of the ways UPMC Health Plan is reducing the rates of avoidable emergency room use, according to Debra Smyers, senior director of program development at UPMC, who presented these strategies during a recent webinar on Identifying, Engaging and Breaking Down Patient Barriers To Reduce Avoidable ED Use.
UPMC developed community teams to engage members who were having “unplanned care” — members who thought of the ER as their own personal PCP. These teams focus primarily on the Medicaid and special needs populations. UPMC sends health plan nurses and social workers into the community to visit the targeted members in their homes. These visits continue for a few months. Then, the nurse or social worker hands the member over to a different caregiver to continue the care.
UPMC calls it a "real team approach;" they even have nurses located in the patient-centered medical home (PCMH) who can link members to an appropriate caregiver, explains Ms. Smyers. For instance, if the member is a smoker and wants to quit, the nurse would link that member to the lifestyle health coach who helps with smoking cessation.
UPMC Health Plan has also placed a patient navigator in the ER to educate patients on appropriate ER use. These navigators ask patients coming into the ER for a minor illness, such as for a sore throat, if there are any care alternatives they could use instead, such as visiting their PCP. Should the patient not have a PCP, the navigator will then help the patient to find one.
Originally, to identify patients using the ER inappropriately, UPMC would go through a monthly stratification process that included data from previous months. However, this identified patients too long after their ER visit, when it was irrelevant to help the patient. The health plan now uses actual registration data from the ERs to find their targeted patients.
With this new plan, UPMC was then able to reach the patient about their ER use on the actual day of the hospital visit. Also, to have a more direct focus on the different patients that were coming into the ER, UPMC stratified all patients into three targeted groups: those with high ER use, those with ER visits for conditions, and those patients with level 1 or 2 ER visits.
Smyers also discussed UPMC's Connected Care Program to help improve care coordination for patients with serious mental illnesses. The health plan based this program on the PCMH model of care to address how physical and behavioral healthcare providers can manage the care of this specific population.
One of the components of this program is integrated care team meetings with staff members to focus on how to support patients with their personal and social needs. For instance, if a patient is constantly going to the ER for an illness only because the ER staff treats them well, the patient needs to understand why that constitutes inappropriate use of the ER.
This UPMC program engaged 2,500 members over two years.
In 2010, UPMC added an ER measure to their pay-for-performance (PFP) program. This measure is made up of two parts: one looks at utilization of the ER in comparison to other practices in the PFP program, and the other part looks at the rate of the practice’s improvement from the previous year.
One of the many outcomes from the ER measure was that in 2011, the PFP practices had a rate of ER visits of 34/1,000 less than the overall performance and 145/1,000 less than the non-PFP practices.