Florida Emergency Department Collaborative Results of ED Utilization Analysis and Initiatives Questionnaire June 8, 201

1. Florida Emergency Department Collaborative Results of ED Utilization Analysis and Initiatives Questionnaire June 8, 2011 Presented by: Howard Pitluk, MD, MPH, FACS, Vice President/Chief Medical Officer Margaret deHesse, RN, BSN, Executive Director State and Corporate Services

2. Plans Who Provided Data

3. ED Utilization Analysis 11 out of 12 plans conducted an Emergency Department utilization analysis

4. When was the Analysis Completed?

5. Did the analysis include identification of visits to the ED that could have been treated by the PCP? Yes No None of the plans used the New York University (NYU) Algorithm for the ED analysis

6. Top Conditions of Avoidable ED Visits

7. Observations of ED Analysis by HMOs/PSNs • A small percentage of members account for a high percentage of ED use (ultra utilizers) • Majority of visits for members < 21 years of age • Majority of visits for members 0-5 years of age

8. Did the Analysis Identify Ultra Utilizers?

9. Conditions of the Ultra Utilizers Each of the following was identified once by the plans as a Top Ten diagnoses of the Ultra Utilizers Each of the following conditions was identified as a Top Ten Condition of Ultra Utilizers by just one plan:

10. Current Initiatives • Member Education and Outreach – • Welcome packets - Location of urgent care centers • Use of 24/7 nurse line • Reminder letter to schedule appointment with PCP • Educational materials on ED use • Encourage linkage to PCP • Assist member with changing PCPs

11. Current Initiatives • Case Manager/Health Coach - • High utilizers – Refer to case/disease management • Assist members with scheduling PCP appointments • Behavioral health co-management • Health coach – Real time follow-up • Provider Education and Outreach – • Educate providers about urgent care options • Notification of member ED use • Notification of high opiate use

12. Current Initiatives • Emergency Department • Daily/ Weekly ED Census • Work with ED Staff to conduct a face-to-face meeting with member and perform an ED assessment

13. Current Initiatives - Evaluation • Sunshine State – • 90 percent of members stopped going to the ER • 10 percent still use multiple times • Greater than 40 percent decrease in ER usage overall • Universal - • Results showed a decrease in ED usage for the pilot county

14. Current Initiatives - Evaluation • Humana - • Pre-evaluation ED usage of the entire population - 5.5 • Post evaluation usage - 4.9 • Pre-evaluation of members who had interventions - 7.4 • Post intervention - 2.3

15. Daily Census from EDs

16. Methods of Receiving Census

17. 24/7 Nurse Advice Line Health Plans

18. Nurse Advice Line Usage • 4 HMO/PSNs have a 24/7 Nurse Advice Line for members

19. Care from Non-PAR Providers

20. Considerations for the ED Collaborative • Member - • Need member education on treating minor ailments • Real time outreach is effective • High illiteracy rate - welcome packets of little benefit • ED - • Lack of communication between EDs • EDs advertise low wait time

21. Considerations for the ED Collaborative • Other • Use mobile diagnostic units for preventive services • High volume of ED use at non-contracted facilities • No link between mental health vendor and MCP regarding ED use driven by mental, alcohol and substance abuse disorders • Underlying diagnoses in children often make ED visits the correct choice

22. Behavioral Health How are members with Behavioral Health conditions who access the ED tracked?

23. A Look at Ohio’s Statewide ED Collaborative

24. Overview • Structure • Statewide Collaborative (IMPROVE) • Five Regional Steering Committees • Patient Streams • Ultra Utilizers: Mental Health, Non-mental Health, Chronic Back Pain • Dental • URI - Statewide

25. Ultra Utilizers Intervention • High utilizers are identified as sample members. • Interdisciplinary Teams develop care treatment plans to establish a coordinated care approach. The goal is to meet the sample members’ needs and re-direct them to their medical home rather than the ED. • Sample members are flagged at participating EDs. • If a member in the sample accesses the ED, the attending ED Physician will: • Reference the care plan summary, and • Notify the Interdisciplinary Team contact person that a sample member has accessed the ED. • The Interdisciplinary Team continually outreaches sample members and coordinates care to reduce avoidable ED visits.

26. NORTHWEST REGION – BACK PAIN Emergency Departments Total patients in test intervention = 13 TEST SITES Toledo Hospital [ED] Mercy St. Vincent [ED] Mercy St Vincent Pain Clinic University of Toledo [ED] Contact: Clinic Manager Care Treatment Plan Integrated Care Team Managed Care Plans (MCPs) Buckeye (5 Sample Patients) Case Managers Care Source (5 Sample Patients) Case Managers Unison (3 Sample Patients) Case Managers

27. Dental Intervention • Business Hours • Medicaid managed care members presenting with dental conditions are identified at the ED. • EDs call participating dental providers and secure a fast-tracked dental appointment for the patient. • EDs forward the identifying information of sample patients to the appropriate MCP. • MCPs follow-up with the member. • After-Hours • ED staff distribute a card listing the MCP contact information and instruct the patient to call the MCP during business hours for a fast-tracked dental appointment.

28. URI Intervention • Sample members receive a kit for colds which promotes the managed care plans’ (MCP) 24-Hour Nurse Advice Line with a “call early, call often” theme • Most sample patients receive the kits through the mail with a letter from their primary care physician (PCP) or their health plans’ medical director. In the real-time test interventions, kits are distributed at the ED. • MCP Nurse Advice Lines triage sample members and bridge services the MCP has to offer with follow-up PCP care • PCP office provides next day/same day appointment scheduling for sample members • An MCP Health Coach follows-up with members in the test intervention sample

29. Questions