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