ICAHN Emergency Department Utilization January 20, 2011 Carrie E. Nelson, MD, MS, FAAFP Carrie.nelsonmckesson

1. ICAHN Emergency Department Utilization January 20, 2011 Carrie E. Nelson, MD, MS, FAAFP Carrie.nelson@mckesson.com

2. Who is Eligible for YHP?

4. Your Healthcare Plus (YHP) Program Design Goal Improve health outcomes & reduce avoidable costs Specific Program Design Concepts Improve coordination of care Support care via primary medical home to minimize fragmented care Reduce inappropriate and unnecessary emergency department (ED) and in-patient hospitalization (IP) utilization Increase member adherence to the provider�s treatment plan Improve self-management knowledge and skills Improve adherence to national, evidence-based clinical practice guidelines Hospital admits & days stay Emergency department Pharmacy DME Hospital admits & days stay Emergency department Pharmacy DME

5. 5 Emergency Departments Overburdened: JAMA August 11, 2010 1997-2007 Datai Visits increased by 23% = double the population growth Number of EDs decreased by 5% Visits by 18-44 year olds accounted for greatest increase Adults with Medicaid increased from 693.9/1000 to 947.2/1000 enrollees Nationally 10% of adults with Medicaid report no usual source of care (IHC addresses this issue in Illinois) EDs meeting safety net criteria increased 43% ? 63% Percent of Patients leaving before being seen 1.05%?1.65%

6. 6 ED Overuse: National Statisticsii 15.6% of symptoms are general in nature: fever, fatigue, and pain 13.8% are musculoskeletal symptoms 13.7% are digestive symptoms 10.7% are respiratory symptoms

7. 7 Consequences of ED Overuse Cost Missed opportunities for PCP to impact chronic conditions and wellness Communication lapses Increase in patients leaving before being seen

8. 8 HFS Data on ED utilization Over 1.8 million ED visits in FY10 for the entire IL Medicaid population Many non-urgent nature Occurring at over 200 hospitals state-wide Top 20 Diagnoses include a mix of medical and behavioral health issues

9. 9 YHP Frequent ED Population Subgroup of Family Health Population with six or more ED visits in 12 months without a subsequent admission >44,000 individuals in FY �09 FrED population tend to high be utilizers of entire healthcare system 83.37% of members had at least one PCP visits in the past 12 months (to any PCP) 56.77% of members had at least one visit to their assigned Medical Home PCP in the past 12 months

10. 10 YHP Data 19 diagnosis codes account for � of the costs associated with ED use and over � of the total visits 34% of these are assessed to be non-urgent Asthma is the #1 ICD-9 cost driver for ED use Other diagnoses in the top 20 include Heart failure with 1.64 visits/ member Diabetes 1.57 visits/member Of the 51% of HFS pts w/ ED visits annually, 6% have > 5 visits with an average of 7.9

11. 11 What do Patients Tell Us? Abdominal pain, chest pain, and fever, account for 16.0 percent of their ED visits Perceived need for medication or pain relief was also found to be a factor that contributed to ED use. A YHP staff survey regarding reasons patients seek care in the ED instead of their PCP, found: Pain relief contributes ~10.9% of the time Need for medication contributes ~11.3% of the time

12. 12 YHP Staff Survey 26.7% stated it was easier to go to ED than get into the PCP 21.1% reported that the PCP directed them to the ED 9.8% state that the office hours are limited or not convenient 7% complain of long waits in the clinic To a lesser degree the reasons �not treated with respect� (3%) and �complicated phone tree� (0.4%) were cited

13. 13 Other Contributors A Department of Social and Health Services in Washington state showed a �connection to narcotics prescriptions, mental health, and substance abuse issues.�iii

14. 14 PCP Access Challenges YHP Staff Survey findings are strongly supported by reference data. A Medicaid managed care organization in Washington State, Columbia United Providers (CUP), found that: 40% of ED utilizers called their PCP first and 62% of these were told to go to the ED (based on a phone survey of 400 members). CUP also found that 28% of visits happened during daytime hours. These findings were similar to those reported by Horizon New Jersey Health

15. 15 Solutions from the Literature An intervention at a location in Tennesseeiv showed within the first four months of the program that when an on-site staff person scheduled non-emergent patients with a PCP for either the same or next day care for their condition: 66% of patients referred from the ED kept their appointment with the PCP and 46% of patients referred demonstrated that they had chosen the PCP as their new medical �home� by having a second clinic visit. Based upon a Horizon Blue Cross Blue Shield of New Jersey programv, a social worker intervention demonstrated success in redirecting frequent ED utilizers to their medical home.

16. Solutions from the Literature: University of Chicago Study Frequent ED users (n = 69); infrequent users (n = 99) Frequent visitors were much more likely to screen positive for depression than infrequent users (47% vs. 27%, respectively, p 0.017) Frequent visitors were more likely to have a primary care physician (75% vs. 66%,respectively) Frequent visitors reported an average of eight visits to their primary care physician per year, whereas infrequent visitors reported making four ED frequent visitors report higher levels of stress and there is a trend toward lower levels of social support from family and significant others

17. 17 YHP Solutions 24 hour Nurse Advice Line For the YHP managed population, especially strong savings by decreasing ED use for: Members with mental health co-morbidities 24% savings was realized for improvements in ED use among patients with schizophrenia 11% savings estimated for those with depression 9% savings for Congestive Heart Failure YHP Social Worker Emergency Department Intervention Early program of ED � YHP Office Health Worker communication for streamlined appointment making YHP staff support available at 800-973-6792

18. YHP Solutions Collaboration with Department of Alcohol and Substance Abuse Community Mental Health Centers Transportation support Housing support Care Transitions Intervention Depression screening (see module on YHPlus.com)

19. 19 Frequent ED Telephonic Intervention Assure member knows who their PCP is If member expresses PCP not a �best fit�, transfer to IHC provider line Identify barriers to use of PCP and work toward solutions Assure member knows how and importance of making and keeping appointments with PCP Supports member to actually make PCP appointment

20. 20 YHP/IHC Solutions in Pilot Phase ED Overuse �Chart Reminders� Clinic-Hospital Pairs Discussions Frequent ED Clinic Performance Improvement

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22. 22 References Ning Tang; John Stein; Renee Y. Hsia; et al. Trends and Characteristics of US EmergencyDepartment Visits, 1997-2007. JAMA. 2010;304(6):664-670. McCaig LF, Nawar EN. National Hospital Ambulatory Medical Care Survey: 2004 emergency department summary. Advance data from vital and health statistics; no 372. Hyattsville, MD: National Center for Health Statistics. 2006. Washington State Department of Social and Health Services. Reduce Emergency Room Utilization. A report to the Legislature Chapter 518, Laws of 2005, Section 507(16) October 2005. Americhoice by United Healthcare. Jason T. Garrett, Director of Communications, News Release, Nashville, December 19, 2008. Horizon NJ Health; Approaches to Addressing the Realities of Emergency Department Use in Medicaid Managed Care. Presented By Pamela Persichilli, CMCN, CPUR, BA 2/1/05 Gordon AB. Open access at primary care partners. Available at: www.ihi.org/IHI/Topics/OfficePractices/Access/ImprovementStories/Open+Access+at+Primary+Care+Partners.htm. Accessed November 09, 2010. R. Lowe, MD, MPH, et al. Association Between Primary Care Practice Characteristics and Emergency Department Use in a Medicaid Managed Care Organization. Medical Care � Volume 43, Number 8, August 2005.