Peach State Health Plan Emergency Room (ER) Management Program Cara Johnson-Malbrough,
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1 Peach State Health Plan Emergency Room (ER) Management Program Cara Johnson-Malbrough, Director of Case and Disease Management
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Peach State Health Plan Emergency Room (ER) Management Program Cara Johnson-Malbrough, Director of Case and Disease Management Services. Emergency Room Management Program. Mission Statement. - PowerPoint PPT Presentation
Transcript of Peach State Health Plan Emergency Room (ER) Management Program Cara Johnson-Malbrough,
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Peach State Health Plan
Emergency Room (ER) Management Program
Cara Johnson-Malbrough,
Director of Case and Disease Management Services
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Emergency Room Management ProgramEmergency Room Management Program
“Peach State Health Plan will help our members grow healthy and
stay healthy by providing access to better healthcare”
Mission Statement
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Purpose
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The purpose of the ER Management Program is to
impact quality and outcome of care received by our members.
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Emergency Management Program
• The ER Management Program takes a dynamic and systematic approach to ensuring that the delivery of care is at the right time and in the right setting in effort to: – Decrease inappropriate ER usage– Promote the establishment of a medical home by our
members– Remove core barriers to why members use the ER– Provide member / provider education on plan benefits
Core Premises
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Emergency Management Program
• Identification Process– ER Frequent User Report
• Claims generated report
• Stratifies members by their condition and number of visits
– Hospital Notifications (Runner List)• 11 participating hospitals ERs
• Participating ERs notify the Plan withing 1 – 7 business days via fax or email
Program Components
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Hospital Notification List by Participating ProvidersHospitals Frequency of Submission
CHOA- Hughes Spalding [daily]
CHOA- Egleston [daily]
CHOA- Scottish Rite [daily]
Colquitt Regional [daily]
Columbus Regional [daily]
Henry Memorial [daily]
Memorial Hospital [daily]
West GA Health System [daily]
Archibold [Biweekly -Monthly ]
Houston [Biweekly -Monthly ]
Phoebe Putney [Biweekly -Monthly ]
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Emergency Management Program
• Outreach Services– NurseWise
– Cenpatico Behavioral Health (CBH)
– Nurtur (Asthma Disease Management)
– Case Management
Program Components
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Emergency Management Program
• NurseWise (24/7 Nurse Helpline) Outreach– Provide targeted education to members identified as using the
hospital ER inappropriately
– Outbound call (manual / Televox) within 24 – 48 hours to complete a screening assessment
– Audio postcard, and informational mailings (i.e. Conjunctivitis, Fever, Cold, Flu and Ear Infection)
– Identifies members with case or disease management needs and refers the case to the Plan for follow-up
Program Interventions
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Emergency Management Program
• Cenpatico Behavioral Health Outreach– Intensive Case Management (ICM) provided by licensed
social workers and allied health workers
– Completion of a comprehensive needs assessment
– Integrated plan of care for members with dual diagnosis
– Development of an individualized plan of care (POC)
– Facilitation of a relationship with a mental health provider
Program Interventions (cont’d)
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Emergency Management Program
• Nurtur (Asthma Disease Management) Outreach– Enrollment into the Disease Management Program
– Outbound call within 24 – 48 hours to complete an health assessment
– Health Coach collaborates with the members’ physician and/or specialist to develop an individual plan of care (POC)
– Home visit by certified respiratory therapist, if indicated
Program Interventions (cont’d)
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Emergency Management Program
• Case Management– ER F/U Assessments
• Assessment, performed post the ER intervention, used to determine if the member remained compliant with the ER discharge plan and followed-up with his/her PCP
– 90 - Day Case Management Program• Staffed by nurse case managers and allied health workers• Case management services provided to members identified as ER
frequent users and non-compliant with the ER discharge plan or the PCP plan of care
• Home visits, performed by CONNECTIONs staff, on members identified with multiple co-morbidities and unable to contact
Program Interventions (cont’d)
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Emergency Management Program
• Peach State recently completed the annual evaluation of the ER Management Program. The results yielded by some of the interventions were not as effective as anticipated.
– Members who received an intervention via audio postcard or informational mailings showed no significant decrease in ER utilization when compared to the peer group who received no intervention
– Predictive Dialing Outreach (Televox) yielded fewer telephonic connections when compared manual outreach
Program Evaluation
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Emergency Management Program
• NurseWise – New enrollees, between ages of 1 -10 and auto-assigned a PCP will
receive an outbound educational call within 90 days of enrollment into the Plan
– Develop and Implemented a new member mini - assessment
• Case Management – Outreach services associated with hospital notifications will be
managed at the Plan
– Educational interventions will target members auto assigned to a PCP
and had with 1-2 ER visits in past 6 months
2010 Program Enhancements
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PSHP ED Case Management Program
Opportunities for Program Expansion
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Emergency Management Program
• Identification– Forge a collaborative partnerships with area ERs to develop
multifaceted strategies for identifying and managing non – urgent ER frequent users
• ER Frequent Users Notification letters
• Reporting– Automatic referral or alert to the Plan within 24 – 48 hours or
next business day after the member is treated in the ER• Standardize reporting format
Opportunities
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PSHP ED Case Management Program
Questions?
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