Reducing Medical Costs and Improving Clinical Care, Coordination & Outcomes by Reducing Admissions for

High Utilizers of Emergency Care ServicesSara Tracy, MSPH

Senior Manager, Emergency Services & South Hospital Operations, Kaiser Foundation Health Plan of Colorado

Kevin Vanderveen, MDColorado Permanente Medical Group Assistant Regional Department Chief,

Emergency Services Physician Director, Telephone Medicine CenterJoanne Whalen, PsyD

Licensed Clinical Psychologist & Behavioral Medicine Specialist, Kaiser Permanente of Colorado

Collaborative Family Healthcare Association 15th Annual ConferenceOctober 10-12, 2013 Broomfield, Colorado U.S.A.

Session #D5b Saturday, October 12, 2013

Faculty Disclosure

We have not had any relevant financial relationships during the past 12 months.

Objectives

• Identify one model of using integrated care teams to reduce emergency room admission rates and

• Recommendations for replication in other health care settings.

• Identify key players in a health care organization needed to implement such a program.

• Identify critical components for successful implementation of care conferences.

“High” utilizers w/ 6 or more visits in one year

• 2010 ED spend alone = $3.8 million• Average visits = 8.7 per 12 months• Average yearly spend per member:

Commercial: $16,500 Medicare: $8,200

• 7.8% connected w/ Chem Dep• 35% connected w/ Mental Health• Remaining 57% not connected w/ either

Type of patients

• Isolated medical issue that results in several ED visits and then resolves (ex: acute MI, trauma, surgical abdomen etc.)

• Chronic pain issues• Misuse of controlled substances• Other chemical dependency issues – i.e. alcohol dependency• Behavioral health issues that manifest as physical complaints (i.e.

anxiety leading to chest pain)• Patients with challenging social issues & possible placement needs

– may be becoming unable to care for self in current situation• Patients with complex medical issues & emergency needs

Why intervene?

• Improve quality of life for patient and improve quality of care patient is receiving

• Improving coordination of care within integrated care system• Reduce cost to patient and organization• Partner w/ local ED’s to help them care for these patients• Reduce unnecessary (& potentially harmful) diagnostic testing &

treatment• Provide support to Primary Care Physician & care teams for

patient

Why Primary Care Interventions

• Everything mentioned on previous slide!• Primary care in most cases has strongest

relationship with patient• Enhance and strengthen the “medical

home”

How we identify ED high utilizing members

• Real time report from many local ED’s on admissions of KP patients – patients with 6 or more visits/year are flagged

• Local Emergency Depts will call KP and notify of frequency of ED visits and/or drug seeking behavior

• Local provider may notice frequency of ED visits

Once patient is identified, what do we do?

• Chart review to identify trends • Convene all providers critical to patient’s care for care

conference• PCP• Nursing team• Behavioral Health/Chem Dependency• Emergency Care Providers• Clinical Pharmacist• Social work/care coordination services• Include outside providers as needed

Purpose of care conference, cont.

• Identify drivers of ED visits• Identify any other support/outreach needed &

who will do it• Review medications if needed & make

changes• Identify interventions

Purpose of care conference

• Notify appropriate outside entities that a care plan is in place (i.e. emergency departments that patient visits)

• Establish plan going forward for future ED visits• Determine next steps & any further follow up or

review needed

Controlled Substance Issues & Solutions

• Ensure there is a written opioid agreement• Explicitly stipulate that controlled substances MUST be

obtained from a single source for chronic pain—verify with state controlled substance database

• Continued receipt of controlled substances tied to certain behaviors—i.e. regular follow-up with behavioral health, evaluation by chemical dependence

• 28 Day refills• Provision for notification of other providers – i.e.

dentists

Behavioral Health

• Reviewing EMR for relevant mental health history

• Outreaching patients to get connected to BH• Educate & support medical staff on dealing

with BH/CD patients• Education & skill building for patients related

to coping w/ pain & BH/CD issues

Barriers

• Financial – patient unable to afford cost of recommended treatment

• Patient willingness and/or ability to participate in recommended treatment plan

• Social and/or family issues• Transportation

Challenges, roadblock, & obstacles

• Buy in from primary care • Practice variation/lack of consistency• Varying financial incentives in different care settings• Documentation of care plan• Perceived loss of physician autonomy• Perceived liability issues• Perceived patient satisfaction issues• Lack of accountability & incentive

Critical Components to successful implementation

• Chart etiquette & standardized documentation of plan

• Key providers involved & invested in care conference

• Buy in from organization leadership• External & internal communication• Consistency in practice & willingness to follow

through w/ plan

Success of the intervention

• Pre and post (12 months each) data from institution of the program in 2010 shows 55% reduction in ED costs and 40% reduction in visits.

• Several patients have completely detoxed off of narcotics completely

• Will not be able to impact all patients

2011 Results

Case Example: Megan

19 year old Caucasian female college student

Frequent ER visit for believed allergic reaction for prior 4 years (one required intubation)

50+ epi pen injections in the last 4 years

# ER visits 12 months Pre-intervention

Pre-intervention ER costs12 months prior

# ER visits 12 months Post intervention

ER Costs12 monthsPost intervention

8 $19,912 1 $974

Megan – Intervention

Allergist recommended test to take in the ER to confirm (dispute) reaction

Confirmation that not having reaction allowed room to work on anxiety

Brief CBT treatment with Behavioral Medicine Specialist (exposure with response prevention, relaxation exercises, challenging irrational thoughts)

Significant improvement in quality of life

Case Example - Susan

48 y/o disabled Caucasian female

Frequent ED & clinic visits over 10 years for migraine headaches – treated with IM cocktail including narcotics

# ER visits 12 months Pre-intervention

Pre-intervention ER costs12 months prior

# ER visits 12 months Post intervention

ER Costs12 monthsPost intervention

29 $11,879 4 $2,526

Susan - Intervention

Departure of previous PCP opened the door for new treatment plan

Discussed with patient weaning her off of narcotics

Initial reaction in first six weeks from patient was anger at providers

Two months post intervention, patient reported only “mild” headaches and had not been back to ED

Case Example - Amy

54 year old female office employee

Known CAD, multiple visits to the ED over the years for chest pain

Co-morbidities of anxiety disorder, breast CA

# ER visits 12 months Pre-intervention

Pre-intervention ER costs12 months prior

# ER visits 12 months Post intervention

ER Costs12 monthsPost intervention

20 $48,431 6 $13,840

Amy - intervention

Care conference included cardiology team who saw Amy often in the office

Added Rx for anxiety when Amy experiences chest pain

Connection with behavioral health provider and teaching re: mindful eating, stress reduction, anxiety management

Patient able to wean off of home oxygen soon after intervention after two years on oxygen

Learning Assessment

Audience Question & Answer

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!