Peach State Health Plan Emergency Room (ER) Management Program Cara Johnson-Malbrough, Director of Case and Disease Ma

1. Peach State Health Plan Emergency Room (ER) Management Program Cara Johnson-Malbrough, Director of Case and Disease Management Services

2. Emergency Room Management Program Mission Statement “Peach State Health Plan will help our members grow healthy and stay healthy by providing access to better healthcare”

3. Emergency Room Management Program Purpose The purpose of the ER Management Program is to impact quality and outcome of care received by our members.

4. Emergency Management Program Core Premises • The ER Management Program takes a dynamic and systematic approach to ensuring that the delivery of care is at the right time and in the right setting in effort to: • Decrease inappropriate ER usage • Promote the establishment of a medical home by our members • Remove core barriers to why members use the ER • Provide member / provider education on plan benefits

5. Emergency Management Program Program Components • Identification Process • ER Frequent User Report • Claims generated report • Stratifies members by their condition and number of visits • Hospital Notifications (Runner List) • 11 participating hospitals ERs • Participating ERs notify the Plan withing 1 – 7 business days via fax or email

6. Emergency Room Management Program Hospital Notification List by Participating Providers

7. Emergency Management Program Program Components • Outreach Services • NurseWise • Cenpatico Behavioral Health (CBH) • Nurtur (Asthma Disease Management) • Case Management

8. Emergency Management Program Program Interventions • NurseWise (24/7 Nurse Helpline) Outreach • Provide targeted education to members identified as using the hospital ER inappropriately • Outbound call (manual / Televox) within 24 – 48 hours to complete a screening assessment • Audio postcard, and informational mailings (i.e.Conjunctivitis, Fever, Cold, Flu and Ear Infection) • Identifies members with case or disease management needs and refers the case to the Plan for follow-up

9. Emergency Management Program Program Interventions (cont’d) • Cenpatico Behavioral Health Outreach • Intensive Case Management (ICM) provided by licensed social workers and allied health workers • Completion of a comprehensive needs assessment • Integrated plan of care for members with dual diagnosis • Development of an individualized plan of care (POC) • Facilitation of a relationship with a mental health provider

10. Emergency Management Program Program Interventions (cont’d) • Nurtur (Asthma Disease Management) Outreach • Enrollment into the Disease Management Program • Outbound call within 24 – 48 hours to complete an health assessment • Health Coach collaborates with the members’ physician and/or specialist to develop an individual plan of care (POC) • Home visit by certified respiratory therapist, if indicated

11. Emergency Management Program Program Interventions (cont’d) • Case Management • ER F/U Assessments • Assessment, performed post the ER intervention, used to determine if the member remained compliant with the ER discharge plan and followed-up with his/her PCP • 90 - Day Case Management Program • Staffed by nurse case managers and allied health workers • Case management services provided to members identified as ER frequent users and non-compliant with the ER discharge plan or the PCP plan of care • Home visits, performed by CONNECTIONs staff, on members identified with multiple co-morbidities and unable to contact

12. Emergency Management Program Program Evaluation • Peach State recently completed the annual evaluation of the ER Management Program. The results yielded by some of the interventions were not as effective as anticipated. • Members who received an intervention via audio postcard or informational mailings showed no significant decrease in ER utilization when compared to the peer group who received no intervention • Predictive Dialing Outreach (Televox) yielded fewer telephonic connections when compared manual outreach

13. Emergency Management Program 2010 Program Enhancements • NurseWise • New enrollees, between ages of 1 -10 and auto-assigned a PCP will receive an outbound educational call within 90 days of enrollment into the Plan • Develop and Implemented a new member mini - assessment • Case Management • Outreach services associated with hospital notifications will be managed at the Plan • Educational interventions will target members auto assigned to a PCP and had with 1-2 ER visits in past 6 months

14. Emergency Room Management Program PSHP ED Case Management Program Opportunities for Program Expansion

15. Emergency Management Program Opportunities • Identification • Forge a collaborative partnerships with area ERs to develop multifaceted strategies for identifying and managing non – urgent ER frequent users • ER Frequent Users Notification letters • Reporting • Automatic referral or alert to the Plan within 24 – 48 hours or next business day after the member is treated in the ER • Standardize reporting format

16. Emergency Room Management Program PSHP ED Case Management Program Questions?