Note: This is an authorized excerpt from 2011 Benchmarks in Reducing Avoidable Healthcare Utilization. To download the entire report, go to http://store.hin.com/product.asp?itemid=4200 or call 888-446-3530.

© 2011, Healthcare Intelligence Network — http://www.hin.com

2011 Benchmarks in Reducing Avoidable Healthcare Utilization:

Data to Drive Down ER Visits and Readmissions

presented by the

Healthcare Intelligence Network

A publication of:The Healthcare Intelligence Network800 State Highway 71, Suite 2Sea Girt, NJ 08750Phone: (732) 449-4468Fax: (732) 449-4463http://www.hin.com

2010 Performance Benchmarks inReducing Avoidable ER Visits90 healthcare organizations share strategies for reducing avoidable visits to hospital

emergency rooms in response to the Healthcare Intelligence Network’s July 2010

e-survey on this topic:

“The biggest challenge is education — getting our 60-plus ED providers all on the

same page and educating our 300-plus staff members to recognize red flag criteria

that case managers could help with.”

> Hospital

“A significant challenge is accuracy in identifying members who would have repeat ER

use.”

> Behavioral health organization

“It is a community/cultural issue. There are incentives for hospital and patient to go

to ED where care is fast and efficient.”

> Health plan

“We have redesigned responsibilities and have one acute care coordinator in each

office and a backup person when the coordinator is out.”

> Physician Service Network/MSO

“Our strategies to get members to appropriate care include understanding how, why and when they’re accessing ED care. Our goal is to move further upstream to intercede and redirect the member prior to the ED visit to attempt to get the member

to the correct venue for their care the first time.”

> Sara Tracy, senior manager of emergency services at Kaiser Foundation Health

Plan of Colorado

© 2011, Healthcare Intelligence Network — http://www.hin.com

2010 Performance Benchmarks in Reducing Avoidable ER Visits

This special report is based on results from the July 2010 Healthcare Intelligence Network Reducing Avoidable ER Visits Benchmark Survey as well as excerpts from recent webinars on promoting appropriate and efficient use of the hospital emergency room.

Contributing AuthorsDr. Karen Amstutz, vice president and medical director of Medicaid and senior markets, WellPointJoe Eppling, RN, MN, CRR , CNAA, BC, director of behavioral health services for East Jefferson General HospitalSara Tracy, senior manager of emergency services at Kaiser Foundation Health Plan of ColoradoBarsam Kasravi, MD, MPH, managing medical director for state-sponsored programs, WellPoint

Executive EditorMelanie MatthewsHIN executive vice president and chief operating officer

Project EditorsPatricia DonovanJessica Papay

Cover DesignJane Salmon

Table of Contents

About the Healthcare Intelligence Network ........................................................... 1-1

Executive Summary ............................................................................................... 1-1

Survey Highlights ..........................................................................................................1-1

Key Findings ..........................................................................................................1-2

Top Strategies and Results ............................................................................. 1-2

Role of the Primary Care Physician ................................................................ 1-2

Promotion of Alternative Health Services ...................................................... 1-2

Methodology ......................................................................................................... 1-3

Respondent Demographics ....................................................................................1-3

Analysis of Responses ...........................................................................................1-4

Handling High Utilizers ................................................................................... 1-4

Alerting PCPs to ED Visits ............................................................................... 1-5

24 Ways to Engage PCPs in ER Utilization Efforts ........................................... 1-5

Tactics for Recently Discharged Patients ........................................................ 1-6

Challenges, Benefits and ROI ..........................................................................1-7

Comparing Responses from Top Three Sectors ........................................................... 1-8

The Hospital Perspective ............................................................................................ 1-9

The Health Plan Perspective........................................................................................ 1-9

Handling Behavioral Health Cases .................................................................1-10

ED Census and Registries ..............................................................................1-10

Future Programs ......................................................................................................... 1-11

Respondents in Their Own Words ........................................................................1-12

Most Successful Strategies to Reduce Avoidable ER Visits ........................................ 1-12

Overcoming Challenges to Reducing Avoidable ER Use .............................................1-14

Conclusion ............................................................................................................1-15

Responses to Questions ...................................................................................... 1-16

Part I: Overall Survey Responses ................................................................................ 1-16

Figure 1: Organizations Affected by Avoidable ER Use .................................1-16

Figure 2: Programs to Reduce Avoidable ER Use ......................................... 1-17

Figure 3: Populations Linked to Avoidable ER Use ....................................... 1-17

Figure 4: Conditions Linked to Frequent Flyers ............................................1-18

Figure 5: Tactics to Discourage Inappropriate ER Use ..................................1-18

Figure 6: Interventions for Recently Discharged Patients ............................1-19

Figure 7: Staffing Models to Reduce Avoidable ER Use ...............................1-19

Figure 8: Program Promotion Methods ...................................................... 1-20

Figure 9: Reduction in Avoidable ER Visits .................................................. 1-20

Figure 10: Program ROI................................................................................. 1-21

Figure 11: Program Implementation Barriers ................................................ 1-21

Figure 12: Respondent Demographics ......................................................... 1-22

© 2011, Healthcare Intelligence Network — http://www.hin.com

Part II: Responses from Hospitals .............................................................................. 1-22

Figure 13: Hospitals - Affected by Avoidable ER Use ................................... 1-22

Figure 14: Hospitals - Programs to Reduce Avoidable ER Use ..................... 1-23

Figure 15: Hospitals - Populations Linked to Avoidable ER Use ................... 1-24

Figure 16: Hospitals - Conditions Linked to Frequent Flyers ....................... 1-24

Figure 17: Hospitals - Tactics to Discourage Inappropriate ER Use .............. 1-25

Figure 18: Hospitals - Interventions for Recently Discharged Patients ........ 1-25

Figure 19: Hospitals - Staffing Models to Reduce Avoidable ER Use ........... 1-26

Figure 20: Hospitals - Program Promotion Methods .................................. 1-26

Figure 21: Hospitals - Reduction in Avoidable ER Visits ................................1-27

Figure 22: Hospitals - Program ROI ..............................................................1-27

Figure 23: Hospitals - Program Barriers ....................................................... 1-28

Part III: Responses from Health Plans ...................................................................... 1-28

Figure 24: Health Plans - Affected by Avoidable ER Use ............................. 1-28

Figure 25: Health Plans - Programs to Reduce Avoidable ER Use ............... 1-29

Figure 26: Health Plans - Populations Linked to Avoidable ER Use ............. 1-29

Figure 27: Health Plans - Conditions Linked to Frequent Flyers .................. 1-30

Figure 28: Health Plans - Tactics to Discourage Inappropriate ER Use ....... 1-30

Figure 29: Health Plans - Interventions for Recently Discharged Patients ... 1-31

Figure 30: Health Plans - Staffing Models to Reduce Avoidable ER Use ...... 1-31

Figure 31: Health Plans - Program Promotion Methods .............................. 1-32

Figure 32: Health Plans - Reduction in Avoidable ER Use ........................... 1-32

Figure 33: Health Plans - Program ROI ........................................................ 1-33

New Frontiers in Reducing Avoidable ER Use ......................................................1-34

Why Individuals Go to the ER.....................................................................................1-34

Figure 34: Why People Use the ED .............................................................. 1-34

Addressing ER Use by the Medicaid Population.........................................................1-35

ER Triage of the Mental Health Patient......................................................................1-36

Figure 35: PEP Job Duties Matrix ................................................................. 1-36

Glossary .............................................................................................................. 1-38

Appendix A: Reducing Reducing Avoidable ER Use Benchmark Survey Tool .........1-39

About the Authors...............................................................................................1-42

© 2011, Healthcare Intelligence Network — http://www.hin.com

© 2011, Healthcare Intelligence Network — http://www.hin.com Page 1-1

About the Healthcare Intelligence Network

The Healthcare Intelligence Network (HIN) is an electronic publishing company providing high-quality information on the business of healthcare. In one place, healthcare executives can receive exclusive, customized up-to-the-minute information in five key areas: the healthcare and managed care industry, hospital and health system management, health law and regulation, behavioral healthcare and long-term care.

Executive Summary

Inappropriate and preventable use of hospital emergency rooms (ERs) is not only an inefficient use of healthcare resources, but also a waste of healthcare dollars. As consumers and payors take on greater responsibility for the efficiency of the healthcare system, healthcare organizations are targeting avoidable ER use. In its July 2010 Reducing Avoidable Emergency Room Visits e-survey, the Healthcare Intelligence Network captured the steps the healthcare industry is taking to reduce avoidable use of the hospital ER through responses provided by 90 healthcare organizations.

Survey Highlights

Close to 94 percent of respondents said avoidable ER visits are a problem for them; 63 percent of these respondents have programs to reduce avoidable ER use.

Almost 72 percent of respondents without programs plan to implement strategies to target avoidable ER usage within the next 12 months.

The majority of preventable ER visits were for conditions that could have been treated more efficiently in another healthcare setting, said 34.1 percent.

Patient education, promotion of urgent care or walk-in centers and assignment of patients to medical homes are the top three programs respondents are using to prevent inappropriate use of the ER. About 29.3 percent said high utilizers were top contributors to avoidable ER use.

Sixty percent of respondents with no program said funding is the greatest barrier to program launch.

Many organizations have made staffing changes such as establishing community collaborations and appointing disease-specific care coordinators.

Page 1-1

One-third of respondents

said high utilizers (the ER’s ‘frequent

flyers’) are the top

contributors to avoidable

ER use.

© 2011, Healthcare Intelligence Network — http://www.hin.com Page 1-20

How do you promote proxy and alternate health services to patients and members?

By what percentage have your efforts reduced avoidable ER visits in your population?

Source: HIN Reducing Avoidable ER Use Survey, July 2010

Figure 8: Program Promotion Methods

Source: HIN Reducing Avoidable ER Use Survey, July 2010

Figure 9: Reduction in Avoidable ER Visits

©2010

©2010

2011 Benchmarks inReducing Hospital Readmissions90 healthcare organizations share their best strategies for reducing avoidable

hospitalizations and their related costs in vulnerable populations:

“Best strategy: Review of discharge instructions and providing a bridge of

communications between the patient, case managers and social workers.”

> Hospital/health system

“Best strategy: Daily evaluation of patients being readmitted within 30 days to

identify process improvements and physician education.”

> Independent Physicians Association

“Using technology to reach out to all patients post-hospitalization.”

> Specialist provider

“Collaborating more between home health and the hospital and developing a more

streamlined process for CHF patients specifically.”

> Hospice, Home health

“In our traditional reimbursement system, we are not getting reimbursed for

transitional care. With that there comes the need to try to improve our processes

across the board. Opportunity is provided through the accountable care organization

model to change some of that process.”

> Carolyn Holder, manager of transitional care, Summa Health System

© 2011, Healthcare Intelligence Network — http://www.hin.com

2011 Benchmarks in Reducing Hospital Readmissions

This second annual special report is based on results from the December 2010 Healthcare Intelligence Network Reducing Hospital Readmissions Benchmark Survey and contains excerpts from recent webinars on readmission reduction strategies.

ContributorsCarolyn Holder, MSN, RN, GCNS-BC, manager of transitional care for Summa Health System Susan Shepard, MSN, MA, RN, CPHRM, director of patient safety education with The Doctors Management Company

Executive EditorMelanie MatthewsHIN executive vice president and chief operating officer

Project EditorPatricia Donovan

Contributing EditorJessica Papay

Cover DesignJane Salmon

Table of Contents

About the Healthcare Intelligence Network ...........................................................2-1

Executive Summary ...............................................................................................2-1

Survey Highlights ..................................................................................................2-2

Key Findings ......................................................................................................... 2-2

Prevalence and Targets of Readmission Reduction Programs ..............................2-2

Program Strategies and Tools ...............................................................................2-3

Impact and ROI .....................................................................................................2-3

Methodology ........................................................................................................ 2-4

Respondent Demographics ................................................................................... 2-4

Analysis of Responses .......................................................................................... 2-4

Overview of Survey ...............................................................................................2-4

Continued Emphasis on Hospital Discharge ........................................................2-6

New Challenge for 2010: Health Literacy a Top Barrier ........................................ 2-7

The Hospital Perspective ......................................................................................2-8

The Long-Term Care Perspective ..........................................................................2-9

Future Programs ................................................................................................. 2-10

Comparison of 2009 Data to 2010 Data................................................................2-11

Respondents in Their Own Words ....................................................................... 2-12

Most Effective Readmission Reduction Strategy ................................................ 2-12

Additional Comments on Reducing Hospital Readmissions ............................... 2-14

Conclusion ........................................................................................................... 2-15

Responses to Questions ......................................................................................2-16

Part I: Overall Survey Responses ........................................................................ 2-16

Figure 1: Respondents with Programs to Reduce Readmissions ....................... 2-16

Figure 2: Targeted Populations ...........................................................................2-17

Figure 3: Targeted Conditions .............................................................................2-17

Figure 4: Patient Identification Tools ................................................................. 2-18

Figure 5: Readmission Prevention Strategies ..................................................... 2-18

Figure 6: Steps Performed at Hospital Discharge .............................................. 2-19

Figure 7: Primary Program Responsibility .......................................................... 2-19

Figure 8: Program-Related Reduction in Hospital Readmissions ...................... 2-20

Figure 9: Program ROI ....................................................................................... 2-20

Figure 10: Reduced Payment for 30-Day Readmissions ..................................... 2-21

Figure 11: Barriers to Reducing Readmission Rates ............................................ 2-21

Figure 12: Planning Program in Next 12 Months ................................................2-22

Figure 13: No Program: Barrier to Program Launch ...........................................2-23

Figure 14: Respondent Demographics ...............................................................2-24

© 2011, Healthcare Intelligence Network — http://www.hin.com

Part II: Responses from Hospitals .......................................................................2-24

Figure 15: Hospitals: Targeted Populations ........................................................2-24

Figure 16: Hospitals: Targeted Conditions ..........................................................2-25

Figure 17: Hospitals: Patient Identification Tools ...............................................2-25

Figure 18: Hospitals: Readmission Prevention Strategies ..................................2-26

Figure 19: Hospitals: Steps Performed at Hospital Discharge ............................2-26

Figure 20: Hospitals: Primary Program Responsibility ....................................... 2-27

Figure 21: Hospitals: Reduction in Hospital Readmissions ................................. 2-27

Figure 22: Hospitals: Program ROI .....................................................................2-28

Figure 23: Hospitals: Reduced Payment for 30-Day Readmissions ....................2-28

Figure 24: Hospitals: Barriers to Reducing Readmissions ..................................2-29

Part III: Responses from Long-Term Care ...........................................................2-29

Figure 25: Long-term Care: Targeted Populations .............................................2-29

Figure 26: Long-term Care: Targeted Conditions .............................................. 2-30

Figure 27: Long-term Care: Patient Identification Tools ................................... 2-30

Figure 28: Long-term Care: Readmission Prevention Strategies ....................... 2-31

Figure 29: Long-term Care: Steps Performed at Discharge ............................... 2-31

Figure 30: Long-term Care: Primary Program Responsibility ............................2-32

Figure 31: Long-term Care: Reduction in Hospital Readmissions ......................2-32

Figure 32: Long-term Care: Program ROI ...........................................................2-33

Figure 33: Longterm Care: Reduced Payment for 30-Day Readmissions...........2-33

Figure 34: Longterm Care: Barriers to Reducing Readmissions .........................2-34

Glossary ..............................................................................................................2-35

Appendix A: Reducing Hospital Readmissions Benchmark Survey Tool ............... 2-36

About the Contributors ...................................................................................... 2-40

© 2011, Healthcare Intelligence Network — http://www.hin.com

© 2011, Healthcare Intelligence Network — http://www.hin.com Page 2-1

About the Healthcare Intelligence Network

The Healthcare Intelligence Network (HIN) is an electronic publishing company providing high-quality information on the business of healthcare. In one place, healthcare executives can receive exclusive, customized up-to-the-minute information in five key areas: the healthcare and managed care industry, hospital and health system management, health law and regulation, behavioral healthcare and long-term care.

Executive Summary

Motivated by health reform initiatives and incentives from public and private payors, healthcare organizations continue to work to reduce avoidable rehospitalizations, especially among Medicare beneficiaries with high-risk, high-utilization illnesses. The Healthcare Intelligence Network’s second annual Reducing Hospital Readmissions e-survey conducted in December 2010 identified a sharp rise in efforts to reduce readmissions for patients with heart failure, which rose 20 percent from 2009 to 2010.

Additionally, the survey found that the number of reported programs to reduce stroke-related readmissions dropped from 47 percent in 2009 to 28 percent in 2010.

Overall, medication non-adherence continues to be the top barrier to reducing hospital readmissions, but low health literacy levels are also creating significant challenges.

Tighter management of care transitions such as the hospital discharge is still the top strategy to reduce readmissions, but chief responsibility for reducing readmissions has shifted from the registered nurse to the case manager, according to responses provided by 90 healthcare organizations to 21 multiple choice and open-ended questions.

According to respondents who have not yet launched programs to reduce readmissions, staffing limitations have replaced cost concerns in 2010 as the top barrier to program implementation. The percentage of respondents who use risk stratification to identify at-risk individuals has remained constant at 58 percent.

Programs to reduce

stroke-related readmissions

dropped significantly

from 2009 to 2010.

Page 2-1

© 2011, Healthcare Intelligence Network — http://www.hin.com Page 2-20

How much have these programs reduced hospital readmissions in your population?

What level of ROI has your program achieved?

Source: HIN Hospital Readmissions SurveyDecember, 2010

Figure 8: Program-Related Reduction in Hospital Readmissions

Source: HIN Hospital Readmissions SurveyDecember, 2010

Figure 9: Program ROI

©2011

©2011