Reducing Preventable Emergency Room Visits October 10, 2012

1. Reducing Preventable Emergency Room VisitsOctober 10, 2012 Emergency Physician, MultiCare Auburn Medical Center; Immediate Past Chair, Washington Chapter American College of Emergency PhysiciansCEO, Providence Centralia Hospital Stephen Anderson, MD Cindy Mayo, FACHE

2. Partnering for Change • Washington State Hospital Association • Washington State Medical Association • Washington Chapter of the American College of Emergency Physicians

3. Emergency Room Overuse: It Is a Problem

4. Medicaid ER Use Is High In the past year: • About 40% of Medicaid clients visited an ER • About 18% of people with private insurance visited an ER Contributing factors: • Lack of primary care • Substance abuse • Mental health

5. State Approaches to Curbing ER Use

6. Ultimate Goal: Reduce Trend Current projected trend Changing the trend

7. An Opportunity: Patients, when possible, should be treated by their primary care provider for non-emergency conditions in order to promote consistent, quality care helping protect physician/hospital payments. • By June 15, 2012 hospitals must have implemented best practices on: • Electronic health information • Patient education • High-user client information/identification • High-user client care plans • Narcotics prescriptions • Prescription monitoring • Use of feedback information • By January 1, 2013 hospitals must demonstrate reduction in low acuity visits • If unsuccessful, physicians and hospitals will suffer major cuts in Medicaid ER payments

8. Best Practices Just First Step • HCA will perform a preliminary fiscal analysis and report to the legislature by January 2013 • Focus: • Outlier hospitals with high rates of unnecessary visits • High ER visits by PRC clients • Low rates of treatment plans for PRC clients • High rates of opiate prescriptions

9. Emergency Department Reports

10. >=5 Visits - ED Visit Rate Per 1000 Medicaid Clients 25 20 15 10 5 Data from HCA 0 2011 January 2012 January 2012 June

11. Low Acuity ED Visit Rate Per 1000 Medicaid Clients 25 20 15 10 5 Data from HCA 0 2012 January 2011 January 2012 June

12. PRC ED Visit Rate Per 1000 Medicaid Clients 8 7 6 5 4 3 2 1 Data from HCA 0 2012 June 2011 January 2012 January

13. Number of Visits per Assigned PRC Client

14. Percent of PRC Patients Seen with Treatment Plan Rapid adoption of care plans even though many hospitals just getting on EDIE.

15. Percent of Visits from Patients with 5 or More Visits in the Last 12 Months

16. Percent of Completed Treatment Plans for PRC Patients

18. Scheduled Drug Average Units Per Prescription at Hospital by Prescriber

19. Visits by PRC Clients with a Narcotic Prescription

20. Prescriber Trends

21. If Unsuccessful Revert to the no-payment policy. $38 million in annual cuts!

22. Ongoing Oversight and Measurement: Emergency Department Workgroup • Health Care Authority • Washington State Chapter of the American College of Emergency Physicians (WA/ACEP) • Washington State Medical Association • Washington State Hospital Association

23. Emergency Department UtilizationOctober 2012 Cindy Mayo, FACHEProvidence Centralia Hospital

24. Providence Centralia Hospital • 128 bed acute care hospital located in Lewis County • On I-5 corridor approximately 30 miles south of Olympia • Lack of primary care providers accepting Medicaid, charity or self-pay • ED Volumes • 2008 – 32,669 • 2009 – 35,273 *Walk-in clinic opened Dec 2009 • 2010 – 33,636 • 2011 – 31,113 Unemployment 13-14% over past 3 years Socio-economics, behavioral health and cultural issues related to inappropriate ED utilization.

25. Baseline 2008 data – 14,297 patients with ED visit triage level 4 or 5 (walk-in clinic, urgent care or dental) • Original data 25% charity and 24% Medicaid • ED Physicians asked us for assistance in resolving issue • Implementation of on campus FQHC walk-in clinic December 2009 (Valley View Health Center) • Establishment of referral and tracking of Dental patients

26. Original Team Participants NamePosition • John McCord, DPM (Retired) Community Board Member, PCH • Cindy Mayo, FACHE Chief Executive, PCH • Dennis Mesaros Chief Operating Officer, PCH • Jeanell Rasmussen Chief Nursing Officer/VP, PCH • Donna Frerich/Anne Schuchmann Emergency Department Director, PCH • Kristen West Executive Director, CHOICE Reg. Health Network • Kelly Delaney Patient Review & Coordination, WA State DSHS • Robert McElhaney, MD Community Board Member, PCH • Paul Williams, MD Medical Staff President, PCH (2009) • Tricia Goldsby, DDS Private Practice Dentist • Isaac Pope, MD Community Pediatrician • Steve Clark Executive Director, Valley View Health Center • Gerda Barlow Director of Quality, PCH • Paula Godfrey, DO Lewis County Emergency Department Physicians • Linda DiRienzo Foundation Director, PCH • Justin Evander Finance, PCH • Sue Killilay Lewis County Behavioral Health • Donna Karvia Board Member, Valley View

27. Target Patient Population and Goals • Reduce Level 4 and 5 triage emergency visits by 10% from 2008 baseline data • Reduce ED visits for dental issues by 10% • Reduce ED patients with repeat/multiple visits for dental issues by 10% • These patients have chronic diseases, behavioral health issues, drug seeking behaviors, dental issues and inability to establish primary care home

28. Implementation December 2009 • Valley View Walk-In Clinic: on hospital campus open 7 days a week, noon-10 pm • Advertised in local paper and local school system • Emergency department post discharge follow-up to Valley View Health Center, Valley View Walk-In Clinic and Valley View Dental Center • Dental referral began June 2009 (modified case management process) • Post acute care discharge referral to Valley View for follow-up visit • Walk-In Clinic opened December 2009 • Walk-In Clinic space donated to Valley View by Providence Centralia Hospital (for first 2 years)

30. 2011 Data

31. 2011 Data Continued…

34. Identify Frequent ED Utilizers Develop Plan of Care ED Consistent Care Program (EDCCP): • Reps from CHOICE, Cascade Mental Health, STECK Clinic, Valley View, DSHS, PCH ED Leadership… • Team meets 2nd Tuesday of the month to review referrals given by staff, LIPs, Molina or EDIE • ED Leadership meets one a month to review referrals and input Plans of Care which are then presented at the monthly meetings • Each person referred to EDCCP has a Plan of Care - Plans of Care are entered into EDIE • An informal letter is sent to the patient and a letter is sent to the PCP (if applicable) advising them of their patient involvement in the program • There are currently 125 patients in the PCH data base • Of note – EDI tracking states there has been a 3% visit reduction in this patient population

35. Patient Sample Letter Providence Centralia Hospital Emergency Departments goal is to provide you with quality medical care. The Emergency Department Consistent Care Program is offered by the hospital and CHOICE Regional Health Network to help achieve this goal.   Emergency departments are designed to provide evaluation, stabilization, and treatment of emergency conditions that threaten life or limb as well as acute illness or injury. Emergency departments are not designed to provide care for chronic, non-emergent conditions or non-urgent illness. When you present to the emergency department at Providence Centralia, you will be evaluated by a physician, nurse practitioner, or physician assistant to determine if you have an emergency medical condition, or are in active labor. If you have an emergency medical condition, or are in active labor, you will be stabilized and treated. If you do not have an emergency condition or do not require admission to the hospital, you will be referred back to your primary care provider to address chronic pain, routine medical problems and medication refills. Controlled medications will be given through the emergency department only if the medical screening examination indicates you have an emergency medical condition and controlled medications are necessary to treat it. The best medical care for you is to have one provider manage your chronic pain, minor illnesses and medications. This cannot be done with sporadic, episodic visits to multiple clinics and emergency departments. If you do not have a primary care provider, CHOICE Regional Health Network can assist you in finding one. CHOICE can also assist you with prescription assistance, Basic Food and other social or health services. You can contact CHOICE at (800) 981-2123, or (360) 493-4550. Our records indicate you have visited Providence Centralia Hospital ____ times in the last year. Through this program we will develop a plan of care for you while you are in the emergency department. We will contact your primary care provider about your plan of care and your use of the emergency department. We will also review the care and treatment you have received at other hospital emergency departments. If you have questions about the process, or would like to have a Health Resources Coordinator help you, please contact CHOICE at (800) 981-2123, or (360) 493-4550. Through this program we hope to provide you with more coordinated and effective care. Sincerely, Paula Godfrey, D.O. Physician Coordinator, Emergency Department Consistent Care Program

36. 2012 FocusEducate All ED Patients Regarding Appropriate Use of Emergency Department ED Utilization Brochure Distributed to: • 18 local MD practices, clinics, pediatrician and specialty offices (to reduce inappropriate office referrals to ED) Chamber of Commerce United Way Centralia College Red Cross Lewis Co Food Bank Homeless Shelter DSHS local offices WorkSource • Local media coverage via interview with KELA radio on 4/3/12 • Attached brochure to be reviewed at ED Staff Meetings on 4/5 and 4/6 with distribution in the ED Discharge packets to begin in late April 2012 • “Where Should You Go for Care” memo to be published in the Community Health Newsletter mailed to every household in Lewis and South Thurston counties the first week of May 2012

37. Insert Patient Brochure here

39. “Where should you go for care?” Example Where should you go for care? When illness, accidents, and injuries happen, where should you go for care? The answer depends on the seriousness and type of illness. Some options for health care include doctor’s offices and clinics, urgent care clinics, and hospital emergency rooms. Providence Centralia Hospital has developed a new tool to help you make the best decision. “Doctor’s Office, Urgent Care Clinic or the EmergencyRoom – A guide to help you choose the best place to go for health care” brochures are now available at the hospital, local health care providers and community organizations throughout the area. While you get the best care when you see your regular health care provider, the brochure gives common examples of when to call the doctor’s office; when to visit an urgent care clinic; and for life-threatening problems when to go to the Emergency Department. Local urgent care and walk-in clinics are listed in the brochure, along with help-line phone numbers for many local insurance providers. For those needing a regular health care provider, all three local Providence Medical Group clinics are accepting new patients, and some same-day appointments are available. Call the clinic in your area for more information: Chehalis Family Medicine 931 S. Market Blvd. 360.767.6300 Rochester Family Medicine 18313 Paulson St. SW. 360.273.8818 Centralia Internal Medicine 1010 South Scheuber Road  360.807.7966 •  PROVIDENCE COMMUNITY HEALTH NEWSLETTER- TO BE MAILED THE FIRST WEEK OF MAY TO EVERY HOUSEHOLD IN SOUTH THURSTON AND LEWIS COUNTY (APPROXIMATELY 40,000 HOUSEHOLDS). THIS IS THE TEXT – TO GO TO DESGIN PRIOR TO PRINT.

40. Providence Centralia Hospital Pediatric After Hours Clinic • Open 6pm-10pm daily • Staffed by local Pediatricians and ARNPS • Goal: Reduce pediatric non-emergent utilization of Emergency Department • Volumes: 2011 – 6,869 2012 (YTD annualized) - 7,762

41. Questions?