Mercy PHO Emergency Department and Inpatient Discharge Process

1. Mercy PHO Emergency Department and Inpatient Discharge Process Tiffany Francis, MPH Lori Vollstaedt, BSN, RN

3. Mercy Physician Community PHO • 145 Primary Care and Specialty Care Physicians • 38 PCPs, 20 utilizing Crimson Care Registry • 6 MIPCT Practices • 3 Hospitals in St. Clair County, MI • St. Joseph Mercy-Port Huron, our affiliate • Port Huron Hospital, independent • St. John-River District

4. Discharge Process • St. Joseph Mercy Port Huron • Daily feed through secure Trinity email system of all inpatient and emergency room discharges • Port Huron Hospital • Daily feed through a secure web portal of all inpatient and emergency room discharges • St. John River District/Outlying Facilities • No current PHO process, though physicians occasionally get their information through portals that they have access to individually.

5. Challenges We Overcame • Working with a “competing” hospital to get data to promote better health in our community • Administrative burden of handling data in a timely manner • Training of offices on what to do with the data • Decreasing ED utilization for PCS diagnosis…a work in constant progress!

6. Internal PHO Process • Team Member accesses both hospital’s discharge files and saves to our local drives in excel • Team Member separates each physician onto its own formatted excel page by group • Physician group excel pages are faxed or emailed securing to each office with DC for that day

7. Registry Component • Discharges for physicians on our registry are added a service entry with a note by our Team • Physician office will then see the service (ER or IP stay) and admitting diagnosis as well as dates of service

8. Care Manager Process • If office is a MIPCT office: • Complex Care Manager accesses the excel file through the shared Trinity drives • CCM makes the calls to patients who are DC from the hospital or ED • Calls are logged on the log the Care Management Team uses • Calls are logged in Crimson when there is a goal set or follow up needed.

9. Office Process • We train our offices to utilize these lists and contact the patients to get them into the officeafter an ED visit or IP admission • Offices value the information and the ability to get patients in quickly for follow up care • Since many health plans incentivize offices for seeing patients post IP stay, our offices really appreciate the daily lists

10. Findings/Quality • We routinely track and share information with our Quality Committee and physicians related to time of day and insurance type. • Find that most ED visits are M-F 9AM-5PM • Most are Medicare • Diagnosis are Primary Care Sensitive

11. Top 10 Diagnosis for ED

12. Time and Insurance September 2013 • 1435 ED Visits between SJMPH and PHH • 654 between hours of 9AM-5PM • 373 between hours of 5PM-9PM • 408 between hours of 9PM-9AM • 115 Uninsured • 246 Medicaid • 644 Medicare • 430 Commercial Insurances

13. MIPCT Success Story 1 • 62 year old female • 3 IP and 7 ED visits in preceding 12 months • UCIDDM, CHF, COPD, O2 Dependent • Inattentive Family

14. MIPCT Patient 1 Plan/Success • Monthly PCP and Care Manager Meetings • Education re: signs and symptoms, impending troubles • Learned to anticipate illness and contact PCP • 1 IP stay and 2 ED visits in last 12 months

15. MIPCT Success Story 2 • 28 year old female • >25 ED visits preceding 12 months • Many ED visits via ambulance • Minor medical history • All ED visits were primary care sensitive

16. MIPCT Patient 2 Plan/Success • Access to Complex Care Manager • Meetings every two weeks • Calls from Care Manager each ED visit • Close working between PCP and Care Mgr. • 3 ED visits in last 12 months

18. Questions?