Social workers in the ED help members access primary care
Plan cuts non-emergency visits by 45%
By locating a social worker in hospital emergency departments to help members overcome barriers to primary care, Horizon NJ Health was able to decrease ED visits by 45% among members who had a face-to-face conversation with the social worker.
The statistics compared the emergency room visits by members enrolled in the Medicaid managed care plan for a year before and a year after the initiative was begun, explains Pamela Persichilli, RNC, manager of clinical services and utilization management for the Trenton, NJ-based managed care organization.
Horizon NJ Health is the state's largest managed care organization for the publicly insured, serving members in all 21 counties in New Jersey.
The health plan embarked on a pilot project, locating a social worker in the ED of a large hospital, after a data analysis showed that a large number of members were using the emergency department for primary care purposes, such as treatment for sore throats and earaches.
The project was so successful that other New Jersey hospitals asked Horizon NJ Health to locate a social worker in their emergency department. As a result, the health plan has social workers located in the EDs at five hospitals.
"When somebody comes in with a minor ailment, such as a sore throat, they tie up the staff and take up the bed for someone who needs to be seen urgently," she says.
It's a capacity issue for the hospitals, Persichilli points out.
"Even when they have a fast-track system to handle non-urgent care, patients with primary care needs can cause a backup in the emergency department," she says.
The purpose of the initiative is to help members establish relationships with physicians they trust and who can develop a relationship with them while managing their care over time, Persichilli says.
For instance, a bladder infection could be an indication of other health issues. A primary care physician who has access to the member's medical condition can monitor it and make sure there is no underlying condition. When a member gets care in the emergency department, the ED physician takes care of the immediate needs but not the follow-up care.
"A primary care physician can not only take care of the earache or sore throat, but can provide continuity of care and ensure that the member gets regular check-ups and other procedures, such as mammograms," she adds.
When a Horizon NJ member comes into the participating EDs, the social worker is alerted. After the member has been treated, the social worker asks to talk with them and conducts a brief assessment to determine the barriers that kept the member from seeking care from a primary care physician.
"We don't interfere with the hospital's operation or the treatment team. We are absolutely respectful of EMTALA and don't interfere with the patient being seen. We don't turn anybody away from the emergency department," she says.
The social workers see all members who were discharged from the emergency department and who don't refuse the interaction. They conduct a short assessment and update telephone numbers, addresses, and family members to contact in case of an emergency.
During the assessment, the social worker asks the members why they didn't go to their primary care physician and if they want to change physicians.
The social workers have wireless computer and cell phones, which give them the tools they need to access the member's coverage and to find out and, if necessary, to change the primary care physician to whom the member was assigned at enrollment.
The majority of members who seek primary care in the emergency department do so because they don't like the physician to whom they were auto-assigned, Persichilli says.
When people are enrolled in managed Medicaid, they don't always do the paperwork up front and choose a physician. In that case, they are automatically assigned to a physician in their area, Persichilli says.
Listening to patient preference
"When that happens, they may see the doctor's name on their card and, for some reason, they don't want to go there. Or, they went to the physician and it wasn't the right fit for them. They don't understand that they can call and change to another physician," she adds.
If the physician to whom they are assigned is what is keeping the member from going to a primary care provider, the social worker can pull up the names of physicians in the area and assign the member to the physician they choose.
The social worker helps the members and may make a follow-up appointment with the primary care physician of their choice. The member will receive a card with the time and date of the follow-up visit, the physician's name and address, and will set up transportation if it is needed.
If transportation is a problem, the social worker can link the member to Horizon NJ Health's transportation network, either through county transportation services or through a contract with a transportation company, to get them back and forth to appointments.
"Once you remove the barriers to care, there's a lot more success in follow-up and adherence," she says.
If the member has a chronic condition such as asthma or diabetes and could benefit from case management or disease management, the social worker gets them enrolled. Often she is able to set up a three-way telephone conversation and introduce the member to the case manager or disease managers who will be working with them.
Before implementing the program with any hospital, Horizon NJ Health conducts a claims analysis to identify the times during the day when the most members visit the emergency department.
"It's not a 9 a.m. to 5 p.m. job. We want to capture as many people as we can. The social workers staff the emergency departments during the times when there are the most visits among our members," Persichilli says.
For instance, peak hours for member visits are 11 a.m. to 7 p.m. at one hospital but are 2 p.m. to 10 p.m for another hospital in another part of the state.
The health plan conducts a claims analysis every six months to make sure that the data haven't changed.
The social workers are off during the days of the week when the volume tends to be lowest. Many work on Saturday and Sunday because those are some of the busiest days in the emergency department.
The master's-prepared social workers who participate in the emergency department initiative were chosen for their ability to understand the culture and language of the community in which the hospital is located.
For instance, the social workers in hospitals with large Latino populations are bilingual and are able to communicate with members who do not speak English.
The program has helped Horizon NJ Health establish a presence in the communities in which the hospitals are located, Persichilli adds.
People in the community have come to the emergency department, not for care, but to talk with the social worker, for help with a variety of issues, such as finding a doctor in their area or getting an appointment with a specialist.
The initiative has helped Horizon NJ Health with the perennial problem of keeping in touch with its publicly insured members who tend to be a transient population.
"We're updating our records and getting new cell phone numbers, new addresses, and relatives we can contact. Some members have said they haven't lived at that address for 10 years but it's what was in their records when they came into the Medicaid system," Persichilli says.
Using the wireless computers, the social workers are able to tap into the system and update the member records in real-time.
By locating a social worker in hospital emergency departments to help members overcome barriers to primary care, Horizon NJ Health was able to decrease ED visits by 45% among members who had a face-to-face conversation with the social worker.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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