Principal Investigator Tina Bacorn RN Overcrowding in Emergency Departments Admission to ED numbers have been increasing Implementation of the Affordable Care Act has increased the numbers considerably ID: 662176
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Slide1
Non-Emergent use of emergency department
Principal Investigator:
Tina Bacorn, RNSlide2
Overcrowding in Emergency DepartmentsAdmission to ED numbers have been increasing. Implementation of the Affordable Care Act has increased the numbers considerably.
Many of these admissions are not true emergencies
Emergency department costs are the most expensive way to receive primary medical careSlide3
Overcrowding in Emergency DepartmentsCauses:
Sluggish processes for patient throughput
Delayed care for patients with life threatening medical conditions
Delayed relief of pain for patients who present with acute injuries or illnesses
Contributes to the ever rising cost of healthcare in AmericaSlide4
Research Study PurposeTo determine the population using the emergency department for non-emergent purposes
To determine the reason for their choice in using the ED for non-emergent purposes
To correct any identified obstacles to alternative primary care
To re-direct patients to more appropriate facilities, the next time they have a similar complaint, by giving them alternative resource information
To educate patients on their medical complaint
ULTIMATELY: Determine ways to reduce the non-emergent population of the EDSlide5
MethodologyConvenience sample of 100 patients was obtainedMonday-Thursday
Within hours of 0900-1500
Genesis East Emergency Department-Fast Track
During months of October and November 2014Slide6
MethodologyInclusion criteria:Must be triaged at level 4 or 5, based on standard ESI
Practitioner to assess the patient and determine the condition to be non-emergent, could be treated else where, non-emergently, with equal care
Exclusion criteria:
Non-english
speaking patients, pregnant patients, and prisoners.Slide7
MethodologyResearch candidates were presented with informed consent explaining the studyUpon verbal consent, a series of questions were asked of the patient including:
age, gender, primary medical complaint, whether or not they had a PCP, insurance status, and reason for choosing the ED for their medical treatment
Based on their answers, patients were given case specific resource handouts, treated by the practitioner, and then dischargedSlide8
AnalysisOf the 100 patients interviewed:52 were female, 48 were male
Median age was 24.5
All 100 patients were residents of Iowa
Answers were divided up into several categories
:
Medical Insurance status
PCP status
Type of medical complaint
Alternative resources givenSlide9Slide10Slide11
Analysis100 % of the patients could have been seen at an Urgent Care facility
86% of the patients could have been seen at PCP within next 3-7 days, with equal care, and with no additional harm
77% reported having a PCP. However, only 6% reported having actually called their PCP to see if they could be seen. The other 71% stated they just assumed they would not be able to get in.
-The difference between sick slots and routine check ups was explained.Slide12
Analysis30% of the patients were given ORA Orthopedics’ walk-in clinic information: Open Monday-Thursday 1700-2000
92% of the patients given ORA reference did not report severe pain or distress and could have waited an additional couple of hours to go here insteadSlide13
Analysis23% of patients reported not having a PCP
Given Genesis “No Doc” phone number: (563-421-DOCS)
Given contact information and hours of operation on the four community health care sites in the QCA
18% of the patients reported not having medical insurance
Given information on how to sign up for the affordable care act, criteria requirements for Medicaid eligibility, contact information on Genesis Financial Counselor Representative, Rachel
Pai
for assistance in signing up
Informed that Community Health Care also has assistance in signing up for the affordable care act insurance
Slide14
Analysis12% of the patients were seen for chronic pain medication refillsAll of these patients had already established PCP care for their condition, but reported not being able to get into see the PCP before they either “ran out of meds” or the meds “weren’t strong enough”
G
iven Genesis policy on chronic pain management in the emergency department
Genesis’ policy is to not treat chronic pain with narcotics due to the national epidemic of narcotic substance abuseSlide15
Analysis3% of the patients were seen for dental painGiven 10 separate references for dental clinics, including the Community Health Care clinic that accepts walk-ins every morning, Mon-Fri, starting at 0715am
Chronic pain policy also explained to those patients who reported the dental pain lasting longer than 6 monthsSlide16
“FAST TRACK” – not so much“Fast Track” is a common area of emergency departments, set aside for minor injuries and illnesses
Fast Track is often overcrowded itself resulting in wait times of over 2 hours (ideal door-door is 30 minutes)
Sometimes it can take 30 min-hour just to get these patients triaged
“Convenience” was the number one reason reported for why the patients chose the ED for their medical needs
May 2015: West campus ED saw approx. 3,200 patients and East campus ED saw approx. 3,000 patientsSlide17
Systematic Reviews of LiteratureThe most tested intervention to reduce the non-emergent use of ED’s was case management
Included a multi-disciplinary team of nurses, social workers, and physicians
Locus of intervention not limited to the hospital and often extended into the community
Strong evidence supporting a full time case manager for “Fast Track”. Case management was essentially what this research project turned into.
“
In 2 before-and-after studies, the reduction in hospital costs was larger than the cost of the case management team.” (
Althaus
et al., 2011, p. 47) Slide18
Fiscal ResponsibilityHigh Risk Population
68% had government funded insurance
18% were self-pay
4% had commercial insuranceSlide19
Fiscal Responsibility
Services and Supplies
Eligible Populations by Family Income
<100% FPL 101-150% FPL >150% FPL
Institutional Care
(inpatient hospital care, rehab care, etc.)
50% of cost for 1st day of care
50% of cost for 1st day of care or 10% of cost
50% of cost for 1st day of care or 20% of cost
Non-Institutional Care
(physician visits, physical therapy, etc.)
$3.90
10% of costs
20% of costs
Non-emergency use of the ER
$3.90
$7.80
No limit
Drugs
Preferred drugs
Non-preferred drugs
$3.90
$3.90
$3.90
$3.90
$3.90
20% of costSlide20
Fiscal Responsibility
Government
insurance pays out based on a set fee schedule. “The Iowa Medicaid Enterprise (IME) fee schedule is a list of the payment amounts, by provider type, associated with the health care procedures and services covered by the IME. Providers are contractually obligated to submit their usual and customary charges but accept the IME fee schedule reimbursement as payment in full.” (Iowa Department of Human Services, 2014
)Slide21
Fiscal ResponsibilityAlternative interventions are now being implemented in ED’s across America due to the financial loss associated with these unpaid bills:
ADVANCED TRIAGESlide22
Advanced TriageNurse and practitioner in the triage roomPractitioner determines whether or not the patient has a life threatening condition or if the potential is there for a life threatening condition to develop
Patients deemed non-emergent are then given resource hand-outs for appropriate alternative facilities, and then discharged w/o treatment.
Estimated door-door time on these patients is less than 10 minutes.Slide23
Advanced Triage
There are three criteria that should be met in order for this process to occur:
1)“The
hospital has determined, after an appropriate medical screening, that the individual does not need emergency medical services.”
2)“An
alternative non-emergency services provider is actually available and accessible in a timely manner to provide the services needed by the individual.”
3)“The
hospital has provided the individual with…the name and location of an alternative non-emergency services provider (as described above);
and
a referral to coordinate scheduling of the individual's treatment by this provider
.”
(
Medicaid.Gov
Keeping America Healthy,
n.d.
)Slide24
Research Study ExtensionsAdditional research forExact amounts of money lost due to unpaid bills of non-emergent population
Fast track case management trial, with follow up phone calls, to identify and address any hurdles the referred patients may have encountered
Percentage differences of non-emergent to emergent patient populations
The policy/procedure and community reactions to those hospitals doing Advanced TriageSlide25
References
Althaus
, F.,
Paroz
, S., Hugli, O.,
Ghali
, W. A.,
Daeppenn
, J.,
Peytremann-Bridevaux
, I., &
Bodenmann
, P. (2011, July). Effectiveness of Interventions Targeting Frequent Users of Emergency Departments: A Systematic Review.
Annals of Emergency Medicine
,
58
(1), 41-52. http://dx.doi.org/10.1016/j.annemergmed.2011.03.007
Genesis Financial and Billing Services. (2014). http://www.genesishealth.com/patients-visitors/billing/assistance/
Huang, Q.,
Thind
, A., Dreyer, J. F., &
Zaric
, G. S. (2010, July 9). The impact of delays to admission from the emergency department on inpatient outcomes.
BMC Emergency Medicine
,
10
(), 16-21. http://dx.doi.org/10.1186/1471-227X-10-16
Iowa Department of Human Services. (2014). http://dhs.iowa.gov/ime/providers/csrp
Kang, H., Black-
Nembhard
, H., Rafferty, C., &
DeFlitch
, C. (2014, October). Patient Flow in the Emergency Department: A classification and Analysis of Admission Process Policies.
Annals of Emergency Medicine
,
64
(4), 335-342. http://dx.doi.org/10.1016/j.annemergmed.2014.04.011
Medicaid.Gov
Keeping America Healthy. (
n.d.
). http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Cost-Sharing/Cost-Sharing-Out-of-Pocket-Costs.html