Reducing 'frequent fliers' in the emergency room
Medicaid members connect with primary care
By using a combination of education and case management, Molina Healthcare of Michigan has decreased the number of members who frequently visit the emergency department with primary care issues.
"We began this initiative after we determined that our emergency department rates were very high and that some of our members were going to the emergency department over and over for problems that could be handled in a primary care setting," says Janet Marino, RN, MSN, CCM, director of utilization management.
Molina Health Care of Michigan is part of a national managed care organization that provides coverage for Medicaid and Medicare members. In Michigan, the HMO has about 210,000 Medicaid members and about 1,300 Medicare members.
The health plan mines claims data each month and identifies frequent users for the emergency room case management program.
Anyone who has visited the emergency department three or more times in a month receives an educational package.
Educating patients
The packet includes information explaining Molina's health care benefits, including the name of the member's primary care provider; a list of urgent care providers; a phone number patients can call to access behavioral medicine services; and the health plan's nurse advice line number.
The letter emphasizes the importance of seeing a primary care physician, reminds the member that Molina provides transportation to doctors' appointments, and includes the transportation number.
Many times, the emergency department visits are the result of the member not understanding the health plan and its benefits, Marino points out.
When members join the program, they have an opportunity to choose a primary care provider. If they don't choose, the plan assigns one to them.
Some of the members in the program don't know how to access their primary care provider and don't know that the health plan will provide transportation for primary care visits. Many of the members in the program have multiple comorbidities. About 18% of the population is disabled.
About two-thirds of members who receive the educational packet curtail their emergency room visits, while about one-third continue to use the emergency room frequently and are referred for case management. The case managers are assigned to a population of members based upon the members' geographic location and provider group.
Members who are referred to case management receive a letter that identifies the nurse case manager who will be working with them and explains case management services.
Using a comprehensive assessment tool, the case managers contact the members and complete an extensive assessment that includes their medical history; home situation and support system; understanding of their disease and medications, including adherence issues; and barriers to getting care.
"The assessment tool helps the nurse determine why the member isn't receiving care in the office setting and how the case manager can help the member learn to manage their care and avoid the emergency department," Marino says.
The case managers put together a care plan based on the members' needs and follow up by telephone on a regular basis.
They work as a team with the health plan's social workers to facilitate behavioral medicine coordination and help with community resources.
"The population we serve frequently needs assistance with social issues as well as medical issues. They may be homeless, without heat, or have other needs," she says.
In the beginning, the case manager may call the member as frequently as twice a week, and then taper off to a few times a month, depending on the member. When the member's emergency room utilization tapers off, the barriers to primary care have been resolved, and the member is able to manage his or her condition, the case manager will close the case.
When the case managers contact the members, they facilitate scheduling needed appointments while they still have the member on the telephone.
"Sometimes the nurse will make a three-way call while the member is on the line and get them into services right away. It's always helpful if we can set appointments when the member is on the line," she says.
If the case manager has any concern about the member's physical condition, home situation, or immediate medical needs, the health plan will send out a home care nurse to evaluate the situation and contact the member's primary care physician if appropriate.
The home care nurse conducts an assessment, evaluates the member's medication adherence, and home situation, and works with the case manager to determine if more support is needed.
One of the plan's medical directors, David Donigian, MD, a board-certified emergency medicine physician, works closely with the case managers on the program. The team conducts case rounds monthly to evaluate the progress of each member.
Many of the members who are using the emergency department have chronic pain. The case managers will help them access a pain management specialist or a pain clinic to help get their pain under control. If the members appear to have substance abuse problems, they are referred to behavioral health.
In the rare case of patients who clearly are drug seeking, the case manager works with Donigan, the plan's pharmacy department, and the primary care physician, as only one treating physician can write the member's prescriptions for pain medicine. The pharmacy won't fill the prescription unless it's signed by that particular physician.
"We try to coordinate with a pain management specialist who can work with the member on pain management. Some members don't know what to do and go to the emergency room to get some relief," she says.
If members quality for one of Molina's specialty case management programs or disease management programs, the case managers refer them to the appropriate program.
Molina's specialized case management programs include: congestive heart failure, chronic obstructive pulmonary disease, cardiovascular disease, end-stage renal disease, oncology, organ transplants, high-risk obstetrical, and pediatrics.
By using a combination of education and case management, Molina Healthcare of Michigan has decreased the number of members who frequently visit the emergency department with primary care issues.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content