Post on 16-Dec-2015
THE HIGH ALERT PROGRAM:HOW COORDINATED CARE PLANS FOR SPECIFIC ED PATIENTS CAN BENEFIT PATIENTS, PROVIDERS AND HOSPITALS
Christopher Ziebell, M.D.
Emergency Service Partners, L.P.
Austin, TX
• Christopher M. Ziebell, MD, FACEP– Emergency Service Partners, LP
High Alert Program Overview
• Introduction/Program Description• Impact on Work Environments• Evaluation/Results
What is the High Alert Program?
• Case Management System– Identifies Patients with Complex Needs– Identifies Patients with Numerous ED Visits– Organizes Clinical Information– Creates a Plan for Future Patient Encounters
Evolution of the High Alert Program
• SERT• Mechanism for filtering out high-utilizers • Behavior modification• Avoids pressure to triage out• Technology breakthrough• Database intervention and development• Narcotic termination letters
The Process
Patient Referral
Patient Chart Review
Treatment Plan Creation
Treatment Plan Implementation
Review
Review
Review
Resource Requirements for Program Development
Patient
Case Management
Social Work
Nursing Director
Medical DirectorAdministrator
IT Support
Database
High Alert Levels
Level 4General Patient Population
Level 3Patients w/ Treatment PlanCompassionate Dialysis • Sickle Cell • CHF
Level 2Suicidal Patient
Level 1Dangerous Patient
Examples of Cases
• Chronic Care Management• Gastric Bypass Patient• Sickle Cell Anemia• Heart Transplant• Fall Precautions• DNR• Management of Homeless Patients• SSI
Your Biggest Challenge?
• Patient Treatment History• Boundaries of Care• Development of the Care Plan• Identify Appropriate Resources• Staff and Patient Follow-up
What Does it Take to Implement?
Sample Policy
• Sample Policy Exists
Relation to New Models of Payment or Care Delivery
• Accountable Care Organizations (ACOs)• Medical Home• Quality Care • Cost Reductions• Hospital Re-admissions• Wellness and Prevention Emphasis
Personal Perception
• Faster• Lower Cost• Higher Quality• Lower Conflict
Medical Director Perspective
Eight reasons HAP is important to our Emergency Departments:
8.Disciplined, standardized process– Holds up to JCAHO/Legal Reviews
Old Model: “Winging It”
Key Processes:
Memory
Rumor
Suspicion
Conflict
*Visit List*
PLAN
Old Model: “Winging It”
Advantages:
• Easy• Already in Use Disadvantages:
• No Continuity• Poly-pharmacy• Liability• Inappropriate • Wasted Resources
Here last week!
Likes Dilaudid
Cousin in Jail!
New Model: High Alert Program
Advantages: Many
Disadvantages:Time-Consuming
Process: • Referrals• Multiple Inputs• Research• Social Work• Case Management• PCP• Documentation• Director Approval• Re-evaluations• Modifications
Medical Director Perspective
Eight reasons HAP is important to our Emergency Departments:
7.Increases physician job satisfaction• Worth the costs of HAP• Does not “tie the MD’s hands”• Not “cookbook medicine”
Medical Director Perspective
Eight reasons HAP is important to our Emergency Departments:
6.Improves the work life of our nurses• Worth the costs of HAP!
• ED “hardest places to work”
• World-wide nursing shortage
• RN/MD partnership on treatment plan
Medical Director Perspective
Eight reasons HAP is important to our Emergency Departments:
5.Involves the ED patients’ private MD• Adds authority to care plan• Engenders trust• Suggests ramifications/consequences to
bad behaviors
He stole my cell phone last Friday!
Medical Director Perspective
Eight reasons HAP is important to our Emergency Departments:
4.Improves quality of care• Detailed synopsis of issues• Necessary steps in workup• Appropriate treatments
Just another OTD patient……
Medical Director Perspective
Eight reasons HAP is important to our Emergency Departments:
3.Improves speed of care• Avoids unnecessary calls• Avoids unnecessary testing
Medical Director Perspective
Eight reasons HAP is important to our Emergency Departments:
2.Exposes non-compliance• 48 visits with nary a PCP visit• 15 different dentist appointments in 1 year!
The care plan says you’re 4 minutes late with my meds!
Medical Director Perspective
Eight reasons HAP is important to our Emergency Departments:
1.Decreases conflicts and tensions• Medical Director gets to be the heavy• Patient / RN / MD all know the drill• Defined endpoints for ED visits
Staff Survey
• Non-scientific poll
• Effort to minimize bias
• 10 questions; multiple-choice
• Sent via e-mail employing SurveyMonkey
• 39 doctors and 60 nurses responded
Survey1…………
2…..…..…
3……….….
Staff Perspective
• Increases physician job satisfaction
SURVEY RESULTS
• 100% believe the HAP makes their job easier.
Staff Perspective
• Improves the work life of our nurses
SURVEY RESULTS
• 75% believe the HAP makes their job easier.
Staff Perspective
• Improves quality of care
SURVEY RESULTS
• 85% of MDs feel quality is improved
• 57% of RNs feel quality is improved
Staff Perspective
• Improves speed of care
SURVEY RESULTS
• 76% of MDs feel LOS is reduced
• 63% of RNs feel LOS is reduced
Staff Perspective
• Decreases conflict and tensions in the ED
SURVEY RESULTS
• 87% of MDs feel conflicts are reduced
• 50% of RNs feel conflicts are reduced
Overall Perspective
Brings a controlled & predictable process to high-stress patient encounters within a chaotic environment
Staff Opinion — VIDEO
Five Strategies for Reducing Unnecessary Visits
• Chronic Care Management• Substance Abuse Screening• Off-Site Center for the Homeless• Primary Care Liaison• Collaborative Clinic
–The Advisory Board
This was written in 1993… …You’ve come a long way Baby!
HAP Enrollments in Study
• Program active at several hospitals• Studied: 7 hospitals with historical data• HAP patients in study:
– 1,269 met inclusion criteria(HAP patients with visit data within the study interval)
Demographics
• 57% male• Are much more commonly 20–40 than our
general population
HAP Patient Visits
Time Frame for Data Collection 40 Months 12/2006 – 4/2010
Total # of Visits in Selected HAP Sites over Period
100.0% 513,829
Total # of HAP Visits 2.3% 11,667
HAP Visits Excluded from Sample
0.9% 4,791
HAP Visits in Study 1.3% 6,876
Study Percentage of Selected Sites and Period
HAP Patient Visits
For 7 Selected Sites within Period
HAP Visits in Study
Site All Visits HAP Visits % of TotalSite A 126,924 2,041 2.67%
Site B 118,953 2,431 3.62%
Site C 92,684 247 0.47%
Site D 49,774 565 2.20%
Site E 36,456 567 2.05%
Site F 13,220 88 0.97%
Site G 75818 937 2.06%
Totals 513,829 6,876 1.34%
For 7 Selected Sites within Period
Interval Sampling-Definition: “HAP Enrollment Interval”
• “Before and After” HAP enrollment intervals were made for each individual patient
• Length of individual intervals were based on patient enrollment date
• “After” HAP enrollment interval consisted of # of days since patient’s enrollment to 5/1/2010
• “Before” interval is then set to equal number of days prior to each patient enrollment
Interval Sampling
StudyEnds
Patient A
Enrollment Date
Post-IntervalPre-Interval
Patient B
Enrollment Date
Post-IntervalPre-Interval
StudyBegins
HAP Enrollments in Study
• Total HAP Visits in study: 6,876
• HAP visits before: 4,526 • HAP visits after: 2,350
• 48% reduction in number of visits
HAP Visits/Patient
# Patients Before HAP Enrollment
# Patients After HAP Enrollment
1 to 6 Visits 1,028 568
6 to 12 197 65
12 to 18 34 29
18 to 24 6 6
24 + 4 6
Totals 1,269 674
Before vs. After Enrollment at Selected Sites Over Entire Period
HAP Visits/Patient
# PatientsBefore
# Patients After
1 to 6 Visits 278 134
6 to 12 137 44
12 to 18 25 26
18 to 24 6 5
24 + 4 3
Totals 450 212
Patients with 2 years of data (1 year interval before and after)
HAP Population:Top Ten Diagnoses
HAP Primary Diagnosis Before After General
LUMBAGO 15.9% 12.6% 6.41%
HEADACHE 14.7% 12.2% 11.5%
NAUSEA WITH VOMITING 14.1% 15.6%
SHORTNESS OF BREATH 10.2% 11.5%
ABDOMINAL PAIN-OTH SPEC SITE 9.6% 8.9% 11.7%
NAUSEA ALONE 9.1% 10.4%
UNS CHEST PAIN 7.3% 9.7% 7.9%
UNS BACKACHE 6.6%
PAIN IN LIMB 6.4% 5.8%
UNS MIGRAINE WO INTRACTABLE MIGRAINE 6.2% 6.8%
HAP Patients Visits in Selected Sites within Study Period
Key Points re: Diagnosis
• Majority have a pain component• Top 3 pain-related diagnoses had
percentage drop• 4 of 10 Top Diagnoses follow general
population
Lab, CT, X-ray Utilization
Virtually unchanged • 2.5% increase in lab tests• 1% decrease in radiology
Neither Lab Tests
X-rays Both 0
200
400
600
800
1000
1200
1400
1600
1800
1504
810
576
1636
756
478
274
842Before
After
Services Utilized
Before: 4,526 After: 2,350
Disposition
Admitted to Hospital
Admitted To ICU
Discharged Transfer0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
14.56%
0.42%
83.09%
1.93%
14.51%
0.73%
82.46%
2.30%
14.19%
0.32%
82.26%
3.23%
Before
After
Gen'l Pop
Length of Visit:Before vs. After
• LOV virtually unchanged
Financial Observation:Professional Only
• HAP Before-Visits shows 11% reduction in collections over general patient population
• HAP After-Visits shows same picture as collection percentages of general patient population
HAP “Before” Patients Payer Mix: HAP vs. General Population
Payer Difference
Charity 3.29% greater
Federal/State 4.79% greater
Self Pay 7.30% greater
Commercial 15.37% lower
HAP Visits Summary
At Selected Sites During Study Period:
• 48% reduction in number of visits
• 7.1% increase in number of visits in general patient population at study sites– using midpoint of study period
Soft Findings
• Decrease in variation and predictability of outcome
• Results in increased patient safety (e.g., decreased radiation)
• Patients appreciate the fact that you know them when dealing with complex needs
• Impact on Patient Satisfaction Scores unknown
Hard Findings
• Reduced visits by 48%• No improvement in the LOV data• No change in percentage of patients to
receive Lab and X-ray, but actual drop in line with drop of visits
• Payer Mix Changes after enrollment to mirror general population
Example from Another Health Care System:
• In the 12 mos pre-HAP (8/1/10-7/31/11), 76 patients had ≥ 11 ED visits 1046 total visits
• In the 12 mos post-HAP (9/1/11-8/31/12), the same 76 patients had 370 visits – 3 had more visits– 1 had same visits– 55 had fewer visits– 17 had zero visits
• 64.6% reduction in ED visits
Does HAP Reduce Cost?
• Identified “Top 20” from 1 01, 2012 through 8 30, 2012.
• ED Case Manager reviewed the ED visit history of each patient for patterns and trends, noting PCP, if any, and type of funding (majority unfunded).
Does HAP Reduce Cost?
• Case Manager and Medical Director reviewed the “Top 20” list, devised patient-specific Care Plans, and sent out notification letters to each “Top 20” patient.
• Case Manager spent a great deal of time coordinating outpatient care with private physicians and community clinics specific to each patient’s needs in order to reduce unnecessary ED visits for non-emergent problems.
Comparison of # Visits9 mos pre-HAP vs. 4 mos post-HAP
31
21
14 14 13 13 13 12 12 12 12 12 12 12 11 11 11 11
4
3
20 0
2 2
0 01
31 2
13
2
7
1 0
0
5
10
15
20
25
30
35
40
4753
1033
9683
3806
7650
8998
3241
1948
4546
6016
1531
3164
6014
4243
8400
4158
9747
1950
6075
7232
2297
4781
8745
2904
6051
4949
0323
4 mos post-HAP
9 mos pre-HAP
Comparison of ED Charges9 mos pre-HAP vs. 4 mos post-HAP
$642,652.63 $132,807.65
0 200,000 400,000 600,000 800,000 1,000,000
9 mos pre-HAP
4 mos post-HAP
Comparison of ED Charges9 mos pre-HAP vs. 4 mos post-HAP (extrapolated out to 9 mos post-HAP)
$642,652.63 $298,817.21
0 200,000 400,000 600,000 800,000 1,000,000
9 mos pre-HAP4 mos post-HAP9 mos post-HAP
A Third Example
Quick look at reduction in ED utilization among patients with repeated visits, after HAP implementation, for site “A” • In the 12 months January 1, 2010 through
December 31, 2010:– 47 patients had 10 or more ER visits –
689 total visits (14.7 visits/pt avg)
A Third Example
• In the 12 months January 1, 2011 through December 31, 2011:– The same 47 patients had 353 visits or a
51.2% reduction (7.5 visits/pt avg) – 7 had more visits– 39 had fewer visits– 1 had zero visits
• This site has no case management support, and the Medical Director does it all himself.
Questions and Answers