Pilot slashes ED visits by Medicaid recipients
Care plans, CM follow-up were keys
A pilot program at MetroHealth Medical Center in Cleveland resulted in significant drops in emergency department visits among Medicaid recipients who were "ultra-users" of emergency care and participated in the one-year study.
The study, which included development of care plans for each patient and counseling with case managers in the primary care office, was part of a statewide initiative by Ohio Medicaid to reduce inappropriate emergency department usage.
In the year of the pilot, there was a 44% reduction in use of the MetroHealth Medical Center emergency department by the patients in the program. When visits to other hospitals in the greater Cleveland area were taken into account, the patients in the pilot reduced their emergency department visits by 29%. Many of the patients who visited other emergency departments were seeking narcotics and had been turned down at MetroHealth's emergency department, according to Alice Stollenwerk Petrulis, MD, medical director for care management at the 500-bed medical center, a safety net public hospital. About 40% of MetroHealth Medical Center's patients are Medicaid recipients.
For the pilot, MetroHealth Medical Center analyzed emergency department use by Medicaid beneficiaries and chose five "ultra-utilizers" for each of the three Medicaid Managed Care plans that covered its patient population. "All of the patients in the pilot were frequent users of our emergency department, but some occasionally went to emergency departments at other hospitals. We chose patients who already had a primary care provider," she says.
Petrulis worked with the patients' primary care providers, a hospital social worker, and the case managers from the health plans to develop a concise care plan for each patient in the pilot and entered it into the patients' medical records where the plans would be seen by the emergency department staff.
The care plans, based on the patients' medical histories and interventions, were bullet points that included information such as "no narcotics to be given except by the primary care physician," and "has had multiple MRIs and CT-scans and doesn't need more." In some instances, the care plan requested that the emergency department staff obtain current contact information for the patient.
Instead of having a black header like the majority of patient records, charts for patients in the pilot had a red header to alert the staff that the patient had a care plan.
During the pilot, the health plan assigned case managers to provide intensive care coordination for patients in the pilot. The case managers made sure the patients had primary care appointments, called them to remind them of the appointments, arranged transportation as needed, and in some cases, went to patients' homes and accompanied them to the appointments. When patients didn't have telephones, the case managers gave them preprogrammed cell phones that they could use to call the case manager or the primary care provider but no one else.
During the one-year pilot, Petrulis met monthly with each plan, reviewed the patients and their emergency department visits, and looked for ways to make sure the patients got the care they needed to stay out of the emergency department. "In some cases, the patients didn't know that they could call their doctor to ask questions instead of visiting the emergency department, and education was enough to curb their excess use of the emergency department," she says.
Collaboration with the health plans was helpful because they had access to claims if the patients visited other emergency departments, Petrulis says.
"The program provided a lot of value to the emergency department staff because the care plans gave them the whole picture of the patient at a glance. The payers saved a lot of money because of the decrease in emergency department visits. The primary care physicians gained better relationships with their patients, but the hospital lost out on fee-for-service payments for emergency department visits," she says.
As a result of the pilot, Ohio Medicaid decided to go forward with the program on a statewide basis and include a cost-sharing component in the program to compensate the hospitals for loss of fee-for-service payments when the emergency department visits were decreased.
"The state learned that avoiding emergency department usage penalizes providers as well as learning the case managers can make a huge difference in ensuring that patients are treated at the appropriate level of care," she says.
The pilot has ended, but the hospital and the managed care plans are still collaborating on ways to keep patients from using the emergency department inappropriately. "They call me if they see a frequent flyer in the emergency department so we can put together a care plan. The emergency department staff does the same. It has been an excellent program in terms of helping us collaborate. Before the pilot, neither the health plan nor the hospital knew who to call when we identified inappropriate use of the emergency department," she says.
A pilot program at MetroHealth Medical Center in Cleveland resulted in significant drops in emergency department visits among Medicaid recipients who were "ultra-users" of emergency care and participated in the one-year study.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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