The Role of the Emergency Department in Reducing Readmissions

1. The Role of the Emergency Department in Reducing Readmissions October 16, 2014 Leslie S Zun, MD, MBA, FAAEM Chairman and Professor Department of Emergency Medicine RFUMS/Chicago Medical School Mount Sinai Hospital Chicago, Illinois

2. Objectives • Understand the financial importance of reducing readmissions • Evaluate different methods of reducing readmissions • Focus on psychiatric patients in the ED • How the ED can contribute to reducing readmissions • Interventions based on before the ED, in the ED and discharged from the ED

3. ED Returns with ReadmissionsRising, KL, et al: Emergency department visits after hospital discharge: a missing part of the equation. Ann Emerge Med. 2013;62:145-150. • 23.8% returned to ED within 30 days • Older, men, English speaking • Associated with AMA (5% AMA vs. 2% not) • Non-specified chest pain • 45.7% of these were readmitted • CHF highest rate 86.6% • Followed by diabetes, complications of device, sickle cell • Conclusion - Importance of collaboration with inpatient, post acute, community based care

4. Before Patient Arrives Risk Factors for ReadmissionAllandeen, N, et al: Refining readmission risk factors for genera medicine patients. J Hosp Med 2011;6:54-60.Mudge. AM, et al: Recurrent readmissions in medical patient: a prospective study. J Hosp Med 2011;6:61-67 • Patient types • African American • Underweight & weight loss • Cognitive function & limited English proficiency • Chronic disease • Depression, cancer, renal failure, CHF • Patients taking 6 or more medications • Prior hospitalization in past 6 months • Lifestyle issues • Poor and Medicaid • Frequent ED patients • Homeless

5. Before Patient ArrivesAnalysis of Readmissions • Review of frequent ED users • Review of frequent readmissions from the ED • By patient • By diagnoses • By ED MD

6. Before Patient Arrives Identification of Seniors at Risk ToolsGraf, CE, et al: Identification of older patients at risk of unplanned readmission after discharge form the emergency department. Swiss Med Weekly. 2012;142:w13327. • Use two tools to determine risk for readmission • Identification of Senior at Risk (ISAR) and Triage Risk Stratification Tool (TRST) • ISAR • TRST – 6 questions • Modest prediction of unplanned readmission after ED visit in patients over 75 years old

7. Before Patient Arrives Reduce Use of EDs • Expand the walk-in and urgent care facilities • Determine which patients have used EDs 3 or more times in the past month • Call these patients to let them know about other resources and link them with health care, practitioners, case management, and disease management • Important role of social workers in ED

8. Psychiatric Patients Mobile Crisis Units and Telepsychiatry • Mobile Crisis Units Jugo, M, Smout, M, Bannister, J: A comparison in hospitalization rates between a community based mobile emergency service and a hospital-based emergency service. Aust N Z Psychiatry 2001;36:504-508. • Comparison of mobile unit to ED admission rate • ED admitted 3x more than mobile units • TelepsychiatryShre, JH, Hilty, DM, Yellowlees, P: Emergency management guidelines for telepsychiatry. Gen Hosp Psych 2007:29:199-206. • High provider and patient satisfaction • Wide variety of diagnosis, age and complaints • Consultations, diagnostic assessment, medication management, family and patient psychotherapy

9. Psychiatric Patients Law Enforcement OutreachAlakeson, V, Pande, N, Ludwig, M: A plan to reduce emergency room boarding of psychiatry. Health Affairs. 2009;9:1637-1642. • Harris County • Comprehensive ED service • 6 core features-help line, mobile outreach, ED psych services, crisis counseling, residential unit • Of 2,352 pts. seen, 4% admitted • Bexar County • Collective responsibility in keeping patient out of ED • Public and private hospitals, public officials, law enforcement, community mental health, court system

10. Inappropriate Admissions • Legal and liability of sending patients home • Secondary utilizes such as police, group homes, nursing homes and families • Send to ED to resolve issues • Lack of appropriate assessment • Difficulty in contacting PCP • Need for collateral information • Problem with obtaining old medical records • Lack of outpatient resources • Housing • Medication • Care givers

11. One Day ReadmissionsPines, JM, et al: Post discharge adverse events for 1-day hospital admissions in older adults admitted from the emergency department. Ann Emerge Med. 2010;56:253-257 • Examined ED readmissions with 1 day stays • 12.1% of all patients • CHF, COPD, prior hx of CHF • 841 patients of 1207 admitted • 12 died within 30 days • 3 had definitive F/U, 4 missed F/U appointment • Questions • Is it due to premature hospital discharge? • Was a one day admission necessary?

12. Admission Criteria Does the Patient Need to Be Admitted? • Not always an easy decision • Reliance on criteria such as the Interqual IS/SI • Use of admission criteria or guidelines for many conditions • Pneumonia, DVT, CHF, PID, asthma • Alternatives to inpatient stay

13. Alternatives to Inpatient Admission • Observational care • Psychiatric Patients • Acute psychiatric stabilization • Crisis respite • Day hospitals • Living room care • Hospital at Home care

14. Discharge to Hospital at Home Leff B: Defining and disseminating the hospital-at-home model. CMAJ. 2009 Jan 20;180(2):156-7. doi: 10.1503/cmaj.081891. • Have EPs, PCPs, and home care staff identify patients to benefit from receiving hospital-level care at home • Physician visits, at least once daily, and 24-hour coverage • Nursing visits, once or twice daily • Telehealth nurses providing remote support • Remote monitoring of key health indicators. • $1,500 less than a comparable inpatient stay

15. Acute Psychiatric Stabilization • Medical evaluation followed by a psychiatric evaluation • Acute Stabilization Unit • Accept transfers from other institutions • Observation from 24-72 hours • Re-start psychiatric medications • Determine need for inpatient care • Clarify diagnosis • Connect with outpatient resources

16. Psychiatric Admission Criteria Does the Patient Need to Be Admitted? • Not always an easy decision • Use of admission criteria or guidelines for many conditions • Risk to self • Risk to others • Unable to care for self • Alternatives to inpatient stay

17. Admission Criteria • Decision support tool Lyons, JS, et l: Predicting psychiatric emergency admissions and hospital outcome. Ed Care 1997;35:79-800. • Criteria: Suicide potential, Danger to others, Severity of symptoms • Predicted 73% of the admissions • Crisis Triage Rating Scale Bengelsdorf, H, et al: A crisis triage rating scale: brief dispositional assessment of patients at risk for hospitalization. J Nerv Mental Disease 1984;172:424-430. • Scores three categories 1-5 • A. Dangerousness • B. Support system • C. Ability to cooperative • Scoring • 9 or more – outpatient/crisis intervention • 8 or less - admit

18. Determination of Suicide Risk Myths • Not all suicidal patients need to be admitted • All patients who want to harm themselves or others need admission • Alcohol and substance intoxicated patients need admission even if they change their mind when they are not clinically intoxicated • All teenagers with suicide gestures or thoughts need admission • Can the Suicidal Patient Go HomeKennedy, SP: Emergency department management of suicidal adolescents. Ann Emerg Med 2004;43:452-480. • Medical treatment not needed • No prior suicidal attempt • No actively suicidal • Adult in house with good relationship and adult agrees to monitor • Adult will move guns and medications • Whom to contact for deterioration • Follow up arranged

19. Psychiatric PatientsED Treatment Interventions • Brief intervention Fleishmann: Effectiveness of brief intervention and contact for suicide attempters: a randomized controlled trial in five countries Bull WHO 2008;86:703-709. • International study of 8 EDS • Brief intervention and enhanced follow up • Reduced number of deaths • Psychiatric service provided in EDDamas, C, et al: Economic impact of crisis intervention in emergency psychiatry: a naturalist stud. Eur Psych 2005;20:562-566. • Psychotherapeutic approach to considering the crisis an event • Counseling of patient and family • Before and after cost and reduction of hospitalizations • Reduced voluntary hospitalizations 19.5% and increased outpatient consultations 14.4%

20. Psychiatric PatientsED Treatment Interventions • Rapid response Greenfield: A rapid-response outpatient model for reducing hospitalization rates among suicidal adolescents Psych Services 2002;53:1574-1579. • Suicidal adolescents in a pediatric ED • Rapid response team psychiatrist & RN with assessment, meds & community follow-up • Lower hospitalization rate • Crisis PlansRuchlewska, A, et al: The effects of crisis plans for patients with psychotic and bipolar disorders: a randomized controlled trial. BMC Psych 2009;41:1-8. • Plans for crisis intervention for patient, patient advocate and/or clinician

21. Medication • Re-start prior meds • Start new medications • Psychiatry via telepsychiatry • Assistance from C and L service • Medications to start in ED • Antidepressants • Antipsychotics • Mood stabilizers • Benzodiazepines

22. For Admitted Patients ED’s Role • Start patient in care management in ED • Case management • Social work • Discharge planning • Pharmacy • Occupational and speech therapy • Nutritional service • Identify patients that are at risk for readmission

23. ED Discharge • Set up follow up appointments Sharma, G, et al: Outpatient follow-up visits and 30 day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease. Arch Intern Med 2010:170:1664-1670. • 62,746 COPD patients , 66.9% had PCP follow up • Patients who follow up visit reduced the risk of an ED visit and readmission • Begin case management Gil, M, et al: Impact of a combined pharmacist and social worker program to reduce hospital readmission J Mang Care Pharm 2013;19:558-583. • Involve social work and pharmacy • Set up home health services • Med reconciliation and F/U phone calls • Communicate with PCP Pang, PS, et al: Patients with acute heart failure in the emergency department: do they all need to be admitted? J Cardiac Fail 2012;18:900-903. • Hand off to primary care

24. For Discharged PatientsED’s Role • Clear, detailed discharge plans tailored to patient, family, clinicians, case managers and payers • Teach self-care • Improved instructions and instruction process • Patient read back • Encourage self-management • Telehealth technology to monitor at home • ED physician/nurse/social worker phone calls • Assign a patient navigator

25. Value of Patient NavigatorBalaban, R, et al:A randomized controlled trial of a patient navigator intervention in reduce hospital readmissions in a safety new healthcare system. CMAR 2013:3:157-158. • Role of patient navigator • Support and guidance throughout healthcare continuum • Coordinates appointments • Maintains communications • Arranges interpreter services • Arranges patient transportation • Facilitates linkages to follow up • Study of patient navigators • 423 patient navigator and 513 in control • 12.1% were readmitted in patient navigator group and 13.6% in control group.

26. What Can the Emergency Department Do? • Before patient arrives • Identify high risk patients • During patient’s ED stay • Use admission criteria • Limit inappropriate admissions • Hospital admissions • Consider alternatives sites of care • Start processes in ED • After the patient is discharged from ED • Connect pt with out patient resources

27. What Can the Emergency Department Do about Psychiatric Patients? • Before patient arrives • Defection programs – mobile crisis and law enforcement collaborations • During patient’s ED stay • ED interventions • Hospital admissions • Appropriate admission criteria • After the patient is discharged from ED • Connect pt with out patient resources

28. Contact Information Leslie Zun, MD Mount Sinai Hospital 1501 S California Chicago, IL  60608 773-257-6957 zunl@sinai.org