Improving Follow-Up Care in Emergency Departments

1. September 22, 2018 E.D. Phone Home: Implementing a team approach to Emergency Department follow-up care and reduction of potentially avoidable visits Tara Corbridge, RN, MPH Quality Manager, Ballard Pediatric Clinic Laura Morano, RN, MA Care Transformation Consultant, Seattle Children’s Care Network Sheryl Morelli, MD Chief Medical Officer, Seattle Children’s Care Network

2. Agenda (90 minutes) • Learning objectives 5 minutes • Scope of the problem 5 minutes • Data trends in ED access 15 minutes • ED access interventions 50 minutes • continuous process improvement strategies • standard approach to ED follow-up • patient education and guidance • Questions 15 minutes

3. Learning Objectives – Focusing on “how” • Apply continuous process improvement strategies to engage practice teams in creating standard work for ED follow-up. • Apply patient centered medical home workflows with and without the aid of technology to systematically follow-up on patients’ ED visits. • Identify three sources of data regarding population specific ED use, and describe how analysis of this data can reveal opportunities to reduce potentially avoidable ED visits. • Describe three opportunities for patient education and anticipatory guidance regarding ED use and the role of the medical home.

4. What is a potentially avoidable ED visit? Medi-Cal defines avoidable ED visits as: A visit that could have been more appropriately managed by and/or referred to a primary care provider in an office or clinic setting. Sources: www.dhcs.ca.gov/.../reports/.../CA2010-11_QIP_Coll_ER_Remeasure_Report_F1.pdf https://wahealthalliance.org/wp-content/uploads/2015/01/Right-Care-Right-Setting-Avoidable-ER-Visits.pdf

5. It’s not a small problem • Using the Medi-Cal definition, the Washington Health Alliance reports: • 25-55% of ED visits (nationally) are potentially avoidable. • 10% of all ED visits across all payers could have potentially been avoided • Medicaid patients have a higher rate of potentially avoidable ED visits • 11.9% of all ED visits by Medicaid patients could have been potentially avoided • 8.5% of all ED visits by commercially insured patients could have been potentially avoided Sources: https://wahealthalliance.org/wp-content/uploads/2015/01/Right-Care-Right-Setting-Avoidable-ER-Visits.pdf

6. It is an expensive problem Over-utilization of ED services has a significant impact on the overall cost of health care $24 million could have been saved in Puget Sound alone Consider what $24 million healthcare dollars could have funded for our patients Sources: https://wahealthalliance.org/wp-content/uploads/2015/01/Right-Care-Right-Setting-Avoidable-ER-Visits.pdf

7. What can we do about it? Take a deeper dive to learn more about trends in ED access We need to know: • Who is going to the ED? • When? • Why? • For what? ….then we can design and implement interventions to seek appropriate care in their medical home.

8. Sources of data • Healthcare agency reports of national and regional statistics • Population health software • EDIE/PreManage • Feedback from patients and families • After hours call center reports with ED dispositions • Claims from MCOs

9. Trends in ED access: Who is accessing the ED? Children with Medicaid coverage were more likely to have at least one ED visit in the past year, compared with the uninsured and those with private coverage Sources: https://www.cdc.gov/nchs/data/databriefs/db160.htm

10. Trends in ED access: By patient age and payer Within our region, the highest rate of potentially avoidable ED visits varies by age and payer: • Medicaid patients: children age 1-9 years have the highest rate • Commercially insured patients: adults aged 20-44 years have the highest rate Sources: https://wahealthalliance.org/wp-content/uploads/2015/01/Right-Care-Right-Setting-Avoidable-ER-Visits.pdf

11. Trends in ED access: When are patients accessing the ED? For children with an ED visit in the past 12 months, the most recent visit was at night or on a weekend, regardless of payer Sources: https://www.cdc.gov/nchs/data/databriefs/db160.htm

12. Peak hours for ED visits in pediatric Medicaid patients

13. Why do families choose the ED instead of Primary Care office? • Convenient option for busy people • Don’t need to make an appointment • Guaranteed to be seen • Wide range of services readily available https://wahealthalliance.org/wp-content/uploads/2015/01/Right-Care-Right-Setting-Avoidable-ER-Visits.pdf When a child is sick, the family wants to be quickly reassured that something serious isn’t going on Open 24 hours per day so you don’t have to take time away from work Sources:

14. Trends in ED access: More of the “why” When visiting the ED for reasons other than the seriousness of the problem, the most common reason was: Their doctor’s office was not open. https://www.cdc.gov/nchs/data/databriefs/db160.htm

15. Another kind of “why”: Fear of the unknown Most common chief complaint for ED visit is….Fever Dr. Barton Schmitt coined the term: Fever phobia • Recent study demonstrated that parents believe a fever could result in serious harm: • Possible central nervous system damage • Seizures • Death The study also concluded that caregivers need education about fever physiology and management Sources: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5298368/

16. Trends in ED access: Seriousness of the medical issue Children with Medicaid were less likely than children with private insurance to visit the ED for reasons reflecting the seriousness of the medical problem https://www.cdc.gov/nchs/data/databriefs/db160.htm

17. Trends in ED access: Seriousness of the medical issue When visiting the ED for reasons that do reflect the seriousness of the problem, the most common reason was: Only a hospital could help. https://www.cdc.gov/nchs/data/databriefs/db160.htm

18. What does the “why” data tell us? • Consider: Does this data match your experience? • What is your current availability for same day visits? • Have you heard this feedback from families? • Do your families know how to access clinical advice after hours? • Is there a need and opportunity for extended or shifted hours? • Later AM start, PM hours after 5pm • Weekend hours • What are your staffing and resources for clinic and telephone triage coverage? • Is your practice meeting expected turnaround times for appointment access and return of phone calls?

19. Data tells the tale…but now what? What steps can primary care teams take to positively influence trends in ED access? Engage patients, families, and team members in: • Continuous process improvement • Medical home workflows • Team approach • Anticipatory guidance

20. Continuous process improvement: the basics QI Essentials Toolkit • Institute for Healthcare Improvement (IHI) • Includes the tools and templates to launch and manage a successful project • 9 tools which include: • Definition • Instructions • Example • Blank template Sources: http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx http://www.ihi.org/resources/Pages/Tools/Quality-Improvement-Essentials-Toolkit.aspx

21. QI Essentials Toolkit: Template flowchart Sources: http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx http://www.ihi.org/resources/Pages/Tools/Quality-Improvement-Essentials-Toolkit.aspx

22. Continuous process improvement: Example flowchart Pediatric patient presents in ED with report of fever Provide instructions for: • Home treatment • Follow up with PCP • Return to ED “if” Confirm patient understanding, reiterate as needed, DC to home with supportive care. Provide emergency treatment Yes Yes Triage in ED: Evidence of symptoms in addition to fever? Triage in ED: Evidence of life threatening symptoms? Triage in ED: Evidence of fever over 100.4 F? Positive response to treatment? Yes Yes No No No No Admit to inpatient service as needed Provide patient/family education re: • Common causes of fever • Supportive care of fever • When to call PCP • When to return to ED Provide patient/family education re: • Fever • When to call PCP • When to return to ED Complete preliminary diagnostic workup Provide treatment as indicated for diagnosed condition Confirm patient understanding, reiterate as needed, DC to home with supportive care.

23. Continuous process improvement case study:How a flowsheet can reduce variation and improve teamwork Situation Non-urgent clinical question Team did not have a shared understanding among providers and RNs regarding escalation of urgent and non-urgent issues. As a result, team members were inundated with multiple requests and families sought care in the ED before receiving a return call from the office. Rx refill Lab orders Sports clearance form Urgent clinical question Charting

24. Continuous process improvement case study:Background – variation of expectations and communication strategies • Variation among RNs and providers regarding the definition of urgency: • Family is at the lab now, no orders in the EMR • Family is at the pharmacy now and has run out of medication • Can we squeeze the patient into clinic today instead of sending them to the ED? • Clinical urgency vs. parental concern vs. lingering non-urgent issue • Rework and repeat requests: • Page, electronic message, and phone call for the same issue • Unintentional miscommunication: • Why didn’t you….. • Vague messages • Variation in turnaround time • No standard for expected return of pages, clinical messages, follow-up phone calls to families etc. • “Batching” • Staff and provider concerns that urgent issues would not be addressed in a timely manner • Variation in preferred communication method: • Never page vs. Always page • Only answer a text page….only answer the second page • Use of shared RN pool vs. Individual RN inbox

25. Continuous process improvement case study:Strategy - Implement an escalation algorithm Incorporate action of all roles in the process Consider clinical urgency and rationale to escalate non-urgent issues Include on-call and continuity providers Consider how soon the issue “needs” to be addressed Establish standards for methods of communication and escalation Establish standards for message content Establish expectations for turnaround time of provider and RN responses Validate with the team Incorporate chain of command

26. Continuous process improvement case study:Results: Enhanced teamwork • Partnership with patients and families: • Streamlined communication resulted in improved response time to families • Improved patient satisfaction • Issues addressed via telephone triage instead of ED visit • Collaboration among team members: • Shared understanding of expectations decreased frustration and unintentional miscommunication • Decreased rework • Decreased unnecessary interruptions Happy ending?

27. Continuous process improvement: How do you know if a workflow is working?

28. QI Essentials Toolkit – PDSA cycle Sources: http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx http://www.ihi.org/resources/Pages/Tools/Quality-Improvement-Essentials-Toolkit.aspx

29. How can these continuous improvement strategies be applied in your practice? • Consider: Current state workflow for ED follow-up • Do all team members follow a standard process for ED follow-up? • Have you received feedback from families regarding transition of care needs? • Is there a need and opportunity for process improvement in these workflows? • Training and documentation • Communication and teamwork • What are your staffing and resources for clinic and telephone triage coverage? • Is your practice meeting expected turnaround times for ED follow-up appointment access and ED follow-up phone calls?

30. Now you have some tools….what about the structure? Consider aspects of the patient centered medical home model relative to ED follow-up AAP defines a medical home as: • An approach to providing comprehensive and high-quality primary care. • A medical home is NOT a building or a place • It extends beyond the walls of a clinical practice • It builds partnerships with clinical specialists, families and community resources • A medical home recognizes the family as a constant in a child’s life and emphasizes partnership between health care professionals and families Sources:

31. Patient centered medical home qualities • A medical home supports: • Improved health outcomes • Reduced health care cost • Increased quality of care • Increased family satisfaction Sources: https://medicalhomeinfo.aap.org/overview/Pages/Whatisthemedicalhome.aspx https://medicalhomeinfo.aap.org/overview/Pages/Whatisthemedicalhome.aspx

32. Patient centered medical home qualities: Balance A medical home should be: Medical home payment should include: • Accessible • Family centered • Continuous • Comprehensive • Coordinated • Compassionate • Culturally effective • Care coordination fee • Fee for service • Quality improvement payment Sources: https://medicalhomeinfo.aap.org/overview/Pages/Whatisthemedicalhome.aspx https://medicalhomes.aap.org/Pages/default.aspx

33. Medical home workflows: Template for ED follow-up Processes to include: • Contact list of local acute care settings • Communication with ED and IP care teams during admission • Monitoring unplanned ED and IP encounters • Follow-up of unplanned ED and IP encounters

34. Medical home workflows: Supportive technology example, EDIE/PreManage • Cohorts: • Stratify ED visits by quantity, visit reason, and timeframe: • 3 visits in 3 months • 3 visits in 6months • 3 visits in 12 months • All ED visits • Asthma visits • Behavioral health visits Patient name Age Time of visit Location • Reports: • Weekly scheduled • Filter by time frame • Notification options: • Dashboard • Real-time email notification

35. Medical home workflows: Supportive technology example, EDIE/PreManage • Patient-specific details: • ED visits by date, location, and chief complaint • Running total of ED visits • Filter by timeframe • Notifications from care team members: • Specific to care in the ED • Contact information for continuity in specific issue • Free-text space

36. Medical home workflows: Ballard Pediatric Clinic Reducing avoidable ED visits at Ballard Pediatric Clinic • Appointment access • Access to clinical advice • Phone follow-up with sick patients • Patient education • ED follow-up Future plans for reducing avoidable ED visits • Appointment access • PreManage • HIE • Asthma QI project • Measurement

37. Messaging to familiesWhy should families care about avoidable ED visits? Less personal care Wasted time, more stress Higher cost Increased risk Sources: https://wahealthalliance.org/wp-content/uploads/2015/01/Right-Care-Right-Setting-Avoidable-ER-Visits.pdf http://www.chadhayesmd.com/should-i-stay-or-should-i-go-why-not-to-take-your-child-to-the-emergency-room/

38. Patient education: Opportunities for anticipatory guidance • Follow up of ED visits • Confirm awareness of medical home availability and contact information • Contingency planning for alternatives to ED • Well visits • Health literacy • Social determinants of health • Developmental stages • Common age for injuries • Poisoning by ingestion • Helmet use • Intro to the practice • New patient welcome packet • Confirm awareness and understanding of medical home • Telephone triage, after-hours coverage etc.

39. Anticipatory guidance: Alternatives to the ED for non-emergent issues Turn to your PCP first Go to urgent care Call a nurse line for advice Review a symptom checker website Sources: https://wahealthalliance.org/wp-content/uploads/2015/01/Right-Care-Right-Setting-Avoidable-ER-Visits.pdf

40. Patient education tool: Self-management handouts Sources: http://www.seattlechildrens.org/safety-wellness/

41. Patient education tool: Online symptom checker Sources: http://www.seattlechildrens.org/safety-wellness/

42. Patient education tool : Phone app symptom checker • Includes: • Definition of the condition • Causes • Links to related symptoms • Care advice Sources: https://www.healthychildren.org/English/tips-tools/symptom-checker/Pages/default.aspx

43. References and links for more information Apps and online symptom checkers: https://health.usnews.com/health-news/blogs/on-parenting/2010/07/08/iphone-app-gives-parents-a-pediatrician-in-their-pocket https://www.healthychildren.org/English/tips-tools/symptom-checker/Pages/default.aspx https://www.healthychildren.org/English/tips-tools/apps/Pages/default.aspx http://www.seattlechildrens.org/safety-wellness/ Medical home: https://www.aap.org/en-us/professional-resources/practice-transformation/medicalhome/Pages/home.aspx https://medicalhomes.aap.org/Pages/default.aspx Process improvement: http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx http://www.ihi.org/resources/Pages/Tools/Quality-Improvement-Essentials-Toolkit.aspx Diversity and health literacy: https://www.healthypeople.gov/ http://www.ihi.org/Pages/default.aspx https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2.html https://www.cdc.gov/healthliteracy/gettraining.html http://www.diversityrx.org/ http://ethnomed.org/ http://xculture.org/

44. Questions?

45. Contact information Tara Corbridge, RN, MPH Quality Manager, Ballard Pediatric Clinic Email: tcorbridge@ballardpeds.com Phone: 206-783-9300 Laura Morano, RN, MA Care Transformation Consultant, Seattle Children’s Care Network Email: laura.morano@seattlechildrens.org Phone: 206-987-3454 Sheryl Morelli, MD Chief Medical Officer, Seattle Children’s Care Network Email: sheryl.morelli@seattlechildrens.org Phone: 206-987-8146

46. Thanks!

47. Appendix A: QI Essentials Toolkit - Flowchart or Process Map Sources: http://www.ihi.org/resources/Pages/Tools/Quality-Improvement-Essentials-Toolkit.aspx

48. Appendix A: (continued)QI Essentials Toolkit - Flowchart or Process Map Sources: http://www.ihi.org/resources/Pages/Tools/Quality-Improvement-Essentials-Toolkit.aspx

49. Appendix B: QI Essentials Toolkit – PDSA Worksheet Sources: http://www.ihi.org/resources/Pages/Tools/Quality-Improvement-Essentials-Toolkit.aspx