THE HIGH ALERT PROGRAM: HOW COORDINATED CARE PLANS FOR SPECIFIC ED PATIENTS CAN BENEFIT PATIENTS,...
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Transcript of THE HIGH ALERT PROGRAM: HOW COORDINATED CARE PLANS FOR SPECIFIC ED PATIENTS CAN BENEFIT PATIENTS,...
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THE HIGH ALERT PROGRAM:HOW COORDINATED CARE PLANS FOR SPECIFIC ED PATIENTS CAN BENEFIT PATIENTS, PROVIDERS AND HOSPITALS
Christopher Ziebell, M.D.
Emergency Service Partners, L.P.
Austin, TX
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• Christopher M. Ziebell, MD, FACEP– Emergency Service Partners, LP
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High Alert Program Overview
• Introduction/Program Description• Impact on Work Environments• Evaluation/Results
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What is the High Alert Program?
• Case Management System– Identifies Patients with Complex Needs– Identifies Patients with Numerous ED Visits– Organizes Clinical Information– Creates a Plan for Future Patient Encounters
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Evolution of the High Alert Program
• SERT• Mechanism for filtering out high-utilizers • Behavior modification• Avoids pressure to triage out• Technology breakthrough• Database intervention and development• Narcotic termination letters
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The Process
Patient Referral
Patient Chart Review
Treatment Plan Creation
Treatment Plan Implementation
Review
Review
Review
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Resource Requirements for Program Development
Patient
Case Management
Social Work
Nursing Director
Medical DirectorAdministrator
IT Support
Database
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High Alert Levels
Level 4General Patient Population
Level 3Patients w/ Treatment PlanCompassionate Dialysis • Sickle Cell • CHF
Level 2Suicidal Patient
Level 1Dangerous Patient
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Examples of Cases
• Chronic Care Management• Gastric Bypass Patient• Sickle Cell Anemia• Heart Transplant• Fall Precautions• DNR• Management of Homeless Patients• SSI
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Your Biggest Challenge?
• Patient Treatment History• Boundaries of Care• Development of the Care Plan• Identify Appropriate Resources• Staff and Patient Follow-up
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What Does it Take to Implement?
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Sample Policy
• Sample Policy Exists
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Relation to New Models of Payment or Care Delivery
• Accountable Care Organizations (ACOs)• Medical Home• Quality Care • Cost Reductions• Hospital Re-admissions• Wellness and Prevention Emphasis
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Personal Perception
• Faster• Lower Cost• Higher Quality• Lower Conflict
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Medical Director Perspective
Eight reasons HAP is important to our Emergency Departments:
8.Disciplined, standardized process– Holds up to JCAHO/Legal Reviews
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Old Model: “Winging It”
Key Processes:
Memory
Rumor
Suspicion
Conflict
*Visit List*
PLAN
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Old Model: “Winging It”
Advantages:
• Easy• Already in Use Disadvantages:
• No Continuity• Poly-pharmacy• Liability• Inappropriate • Wasted Resources
Here last week!
Likes Dilaudid
Cousin in Jail!
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New Model: High Alert Program
Advantages: Many
Disadvantages:Time-Consuming
Process: • Referrals• Multiple Inputs• Research• Social Work• Case Management• PCP• Documentation• Director Approval• Re-evaluations• Modifications
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Medical Director Perspective
Eight reasons HAP is important to our Emergency Departments:
7.Increases physician job satisfaction• Worth the costs of HAP• Does not “tie the MD’s hands”• Not “cookbook medicine”
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Medical Director Perspective
Eight reasons HAP is important to our Emergency Departments:
6.Improves the work life of our nurses• Worth the costs of HAP!
• ED “hardest places to work”
• World-wide nursing shortage
• RN/MD partnership on treatment plan
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Medical Director Perspective
Eight reasons HAP is important to our Emergency Departments:
5.Involves the ED patients’ private MD• Adds authority to care plan• Engenders trust• Suggests ramifications/consequences to
bad behaviors
He stole my cell phone last Friday!
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Medical Director Perspective
Eight reasons HAP is important to our Emergency Departments:
4.Improves quality of care• Detailed synopsis of issues• Necessary steps in workup• Appropriate treatments
Just another OTD patient……
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Medical Director Perspective
Eight reasons HAP is important to our Emergency Departments:
3.Improves speed of care• Avoids unnecessary calls• Avoids unnecessary testing
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Medical Director Perspective
Eight reasons HAP is important to our Emergency Departments:
2.Exposes non-compliance• 48 visits with nary a PCP visit• 15 different dentist appointments in 1 year!
The care plan says you’re 4 minutes late with my meds!
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Medical Director Perspective
Eight reasons HAP is important to our Emergency Departments:
1.Decreases conflicts and tensions• Medical Director gets to be the heavy• Patient / RN / MD all know the drill• Defined endpoints for ED visits
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Staff Survey
• Non-scientific poll
• Effort to minimize bias
• 10 questions; multiple-choice
• Sent via e-mail employing SurveyMonkey
• 39 doctors and 60 nurses responded
Survey1…………
2…..…..…
3……….….
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Staff Perspective
• Increases physician job satisfaction
SURVEY RESULTS
• 100% believe the HAP makes their job easier.
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Staff Perspective
• Improves the work life of our nurses
SURVEY RESULTS
• 75% believe the HAP makes their job easier.
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Staff Perspective
• Improves quality of care
SURVEY RESULTS
• 85% of MDs feel quality is improved
• 57% of RNs feel quality is improved
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Staff Perspective
• Improves speed of care
SURVEY RESULTS
• 76% of MDs feel LOS is reduced
• 63% of RNs feel LOS is reduced
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Staff Perspective
• Decreases conflict and tensions in the ED
SURVEY RESULTS
• 87% of MDs feel conflicts are reduced
• 50% of RNs feel conflicts are reduced
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Overall Perspective
Brings a controlled & predictable process to high-stress patient encounters within a chaotic environment
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Staff Opinion — VIDEO
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Five Strategies for Reducing Unnecessary Visits
• Chronic Care Management• Substance Abuse Screening• Off-Site Center for the Homeless• Primary Care Liaison• Collaborative Clinic
–The Advisory Board
This was written in 1993… …You’ve come a long way Baby!
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HAP Enrollments in Study
• Program active at several hospitals• Studied: 7 hospitals with historical data• HAP patients in study:
– 1,269 met inclusion criteria(HAP patients with visit data within the study interval)
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Demographics
• 57% male• Are much more commonly 20–40 than our
general population
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HAP Patient Visits
Time Frame for Data Collection 40 Months 12/2006 – 4/2010
Total # of Visits in Selected HAP Sites over Period
100.0% 513,829
Total # of HAP Visits 2.3% 11,667
HAP Visits Excluded from Sample
0.9% 4,791
HAP Visits in Study 1.3% 6,876
Study Percentage of Selected Sites and Period
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HAP Patient Visits
For 7 Selected Sites within Period
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HAP Visits in Study
Site All Visits HAP Visits % of TotalSite A 126,924 2,041 2.67%
Site B 118,953 2,431 3.62%
Site C 92,684 247 0.47%
Site D 49,774 565 2.20%
Site E 36,456 567 2.05%
Site F 13,220 88 0.97%
Site G 75818 937 2.06%
Totals 513,829 6,876 1.34%
For 7 Selected Sites within Period
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Interval Sampling-Definition: “HAP Enrollment Interval”
• “Before and After” HAP enrollment intervals were made for each individual patient
• Length of individual intervals were based on patient enrollment date
• “After” HAP enrollment interval consisted of # of days since patient’s enrollment to 5/1/2010
• “Before” interval is then set to equal number of days prior to each patient enrollment
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Interval Sampling
StudyEnds
Patient A
Enrollment Date
Post-IntervalPre-Interval
Patient B
Enrollment Date
Post-IntervalPre-Interval
StudyBegins
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HAP Enrollments in Study
• Total HAP Visits in study: 6,876
• HAP visits before: 4,526 • HAP visits after: 2,350
• 48% reduction in number of visits
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HAP Visits/Patient
# Patients Before HAP Enrollment
# Patients After HAP Enrollment
1 to 6 Visits 1,028 568
6 to 12 197 65
12 to 18 34 29
18 to 24 6 6
24 + 4 6
Totals 1,269 674
Before vs. After Enrollment at Selected Sites Over Entire Period
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HAP Visits/Patient
# PatientsBefore
# Patients After
1 to 6 Visits 278 134
6 to 12 137 44
12 to 18 25 26
18 to 24 6 5
24 + 4 3
Totals 450 212
Patients with 2 years of data (1 year interval before and after)
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HAP Population:Top Ten Diagnoses
HAP Primary Diagnosis Before After General
LUMBAGO 15.9% 12.6% 6.41%
HEADACHE 14.7% 12.2% 11.5%
NAUSEA WITH VOMITING 14.1% 15.6%
SHORTNESS OF BREATH 10.2% 11.5%
ABDOMINAL PAIN-OTH SPEC SITE 9.6% 8.9% 11.7%
NAUSEA ALONE 9.1% 10.4%
UNS CHEST PAIN 7.3% 9.7% 7.9%
UNS BACKACHE 6.6%
PAIN IN LIMB 6.4% 5.8%
UNS MIGRAINE WO INTRACTABLE MIGRAINE 6.2% 6.8%
HAP Patients Visits in Selected Sites within Study Period
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Key Points re: Diagnosis
• Majority have a pain component• Top 3 pain-related diagnoses had
percentage drop• 4 of 10 Top Diagnoses follow general
population
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Lab, CT, X-ray Utilization
Virtually unchanged • 2.5% increase in lab tests• 1% decrease in radiology
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Neither Lab Tests
X-rays Both 0
200
400
600
800
1000
1200
1400
1600
1800
1504
810
576
1636
756
478
274
842Before
After
Services Utilized
Before: 4,526 After: 2,350
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Disposition
Admitted to Hospital
Admitted To ICU
Discharged Transfer0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
14.56%
0.42%
83.09%
1.93%
14.51%
0.73%
82.46%
2.30%
14.19%
0.32%
82.26%
3.23%
Before
After
Gen'l Pop
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Length of Visit:Before vs. After
• LOV virtually unchanged
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Financial Observation:Professional Only
• HAP Before-Visits shows 11% reduction in collections over general patient population
• HAP After-Visits shows same picture as collection percentages of general patient population
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HAP “Before” Patients Payer Mix: HAP vs. General Population
Payer Difference
Charity 3.29% greater
Federal/State 4.79% greater
Self Pay 7.30% greater
Commercial 15.37% lower
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HAP Visits Summary
At Selected Sites During Study Period:
• 48% reduction in number of visits
• 7.1% increase in number of visits in general patient population at study sites– using midpoint of study period
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Soft Findings
• Decrease in variation and predictability of outcome
• Results in increased patient safety (e.g., decreased radiation)
• Patients appreciate the fact that you know them when dealing with complex needs
• Impact on Patient Satisfaction Scores unknown
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Hard Findings
• Reduced visits by 48%• No improvement in the LOV data• No change in percentage of patients to
receive Lab and X-ray, but actual drop in line with drop of visits
• Payer Mix Changes after enrollment to mirror general population
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Example from Another Health Care System:
• In the 12 mos pre-HAP (8/1/10-7/31/11), 76 patients had ≥ 11 ED visits 1046 total visits
• In the 12 mos post-HAP (9/1/11-8/31/12), the same 76 patients had 370 visits – 3 had more visits– 1 had same visits– 55 had fewer visits– 17 had zero visits
• 64.6% reduction in ED visits
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Does HAP Reduce Cost?
• Identified “Top 20” from 1 01, 2012 through 8 30, 2012.
• ED Case Manager reviewed the ED visit history of each patient for patterns and trends, noting PCP, if any, and type of funding (majority unfunded).
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Does HAP Reduce Cost?
• Case Manager and Medical Director reviewed the “Top 20” list, devised patient-specific Care Plans, and sent out notification letters to each “Top 20” patient.
• Case Manager spent a great deal of time coordinating outpatient care with private physicians and community clinics specific to each patient’s needs in order to reduce unnecessary ED visits for non-emergent problems.
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Comparison of # Visits9 mos pre-HAP vs. 4 mos post-HAP
31
21
14 14 13 13 13 12 12 12 12 12 12 12 11 11 11 11
4
3
20 0
2 2
0 01
31 2
13
2
7
1 0
0
5
10
15
20
25
30
35
40
4753
1033
9683
3806
7650
8998
3241
1948
4546
6016
1531
3164
6014
4243
8400
4158
9747
1950
6075
7232
2297
4781
8745
2904
6051
4949
0323
4 mos post-HAP
9 mos pre-HAP
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Comparison of ED Charges9 mos pre-HAP vs. 4 mos post-HAP
$642,652.63 $132,807.65
0 200,000 400,000 600,000 800,000 1,000,000
9 mos pre-HAP
4 mos post-HAP
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Comparison of ED Charges9 mos pre-HAP vs. 4 mos post-HAP (extrapolated out to 9 mos post-HAP)
$642,652.63 $298,817.21
0 200,000 400,000 600,000 800,000 1,000,000
9 mos pre-HAP4 mos post-HAP9 mos post-HAP
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A Third Example
Quick look at reduction in ED utilization among patients with repeated visits, after HAP implementation, for site “A” • In the 12 months January 1, 2010 through
December 31, 2010:– 47 patients had 10 or more ER visits –
689 total visits (14.7 visits/pt avg)
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A Third Example
• In the 12 months January 1, 2011 through December 31, 2011:– The same 47 patients had 353 visits or a
51.2% reduction (7.5 visits/pt avg) – 7 had more visits– 39 had fewer visits– 1 had zero visits
• This site has no case management support, and the Medical Director does it all himself.
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Questions and Answers