MaineCare Collaborative Care: Reducing Avoidable ED Visits

1. Emergency Department (ED)Collaborative Audrey Pratt 1/28/2019

2. ED Collaborative Background • Emergency Departments (ED) are intended for emergency use only, and services performed there can be costly. • In 2010, after identifying that some MaineCare members were consistently overutilizing the ED or using the ED inappropriately, the Department implemented the ED Care Collaborative to reduce avoidable and costly trips to the ED. This was also important because a member’s primary care or behavioral health provider will have a better understanding of the member’s medical history and needs than ED physicians. • The program was expanded to involve all hospital EDs in the state by 2014. Maine Department of Health and Human Services

3. ED Collaborative Goals • Reduce avoidable ED use and improve health outcomes for high utilizers through statewide care management efforts • Provide care management resources through primary care • Identify and fill the gaps where no care management capacity exists • Increase availability of ED for true emergency situations • Achieve savings in order to reinvest in primary care and other priorities • Educate providers on implementing program processes • Empower and support members to become more engaged in their own wellness Maine Department of Health and Human Services

4. MaineCare Care Management Approach Partner and collaborate with: • Hospitals • Primary Care Provider (PCP) offices • Behavioral Health providers • State agencies • Community Care Teams • Emergency personnel • Other statewide providers, to ensure a consistent plan to avoid duplicating efforts Maine Department of Health and Human Services

5. Care Management Team Our care management team consists of: • Four nurses • Two Behavioral Health Specialists • Two Medical Care Coordinators • One clinical supervisor • One director Maine Department of Health and Human Services

6. Barriers • Inability to contact a member • Homelessness • Behavioral health issues • Substance abuse • Providers who discharge members • No consequence for non-compliance of Individual Service Plan Maine Department of Health and Human Services

7. Care Management Process • Step 1: Identify member • Step 2: Primary Care Provider (PCP) verification or selection • Step 3: Case review • Step 6: Hospital meeting • Step 5: Member education and problem solving • Step 4: Partnership with PCP, Behavioral Health, and other health providers • Step 7: Care planning • Step 8: Four month follow-up • Step 9: Close case Maine Department of Health and Human Services

8. Dental Management Approach • Identify members who go to the ED with dental pain or infection • Coordinate formal referral, treatment plan, and follow-up care with a dentist • Coordinate transportation to the visit • Track dental care received Maine Department of Health and Human Services

9. Behavioral Health Management Approach • Research claims data for current care management services • Work with providers to submit a revised Individual Service Plan that includes ED usage and other goals • Educate members on resources available and assist with referrals as needed • Coordinate provider and member team meetings to determine goals and plan of care • Report all ongoing results to all providers working with the members Maine Department of Health and Human Services

10. Next Steps • Concentrate on sub-populations like MaineCare members without a PCP and pregnant members. • Partner with Value-Based Purchasing (Behavioral Health Homes, Health Homes, and Opioid Health Homes) to identify members in need of care management services • Partner with Change Healthcare for pharmacy management • Partner with MaineCare’s Case Coordination Unit to manage care for members with complex health needs Maine Department of Health and Human Services

11. Questions? Audrey Pratt, RN Nurse Supervisor Audrey.pratt@maine.gov Maine Department of Health and Human Services