Medicaid Quality Incentive: Plan for Reducing Preventable Emergency Room Visits

1. Medicaid Quality Incentive: Plan for Reducing Preventable Emergency Room Visits Department of Social and Health Services Health & Recovery Services Administration Thuy Hua-ly Jeff Thompson Vazaskia Caldwell Beverly Court April 19, 2011

2. Medicaid Quality Incentive Policy Intent • Engage hospitals in quality improvement • “Float all boats” rather than rewarding highest • Pairing monetary incentive with collaborative learning and “safe table” forums • Systems approach (include community partners) • Focus on Medicaid managed care population

3. Incentive Structure Five Measures • Healthcare Worker Flu Immunization • Patient Discharge Information • Elective Delivery Prior to 39 Weeks • Reducing Preventable Emergency Room Visits • Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification

4. Incentive Scoring • Each measure scores 0, 3, 5 or 10 points • Hospital qualifies for 1% rate increase if has average score of 5 or higher • Public acknowledgement of hospitals with average of 10 points • No partial or pro-rated incentive payments allowed by the enabling legislation.

5. Reducing Preventable Emergency Dept Visits Measure • First year – a comprehensive hospital plan • Plan has 5 sections • Community Partnerships • Data Reporting • Strategic Plan for Prevention of Visit • Emergency Room Visit Follow-up • Continuing Education • Points • 3 sections – 3 points • 4 sections – 5 points • 5 sections – 10 points

6. Section 1: Community Partnerships Documentation that infrastructure is in place which includes relevant community partners • Name and addresses of Emergency Departments, both on and off campus • Names and positions of hospital staff and community partners in workgroup. • Minutes of workgroup meetings with future meeting dates. Workgroup with relevant community partners must have met at least once prior to plan approval.

7. Section 2: Data Reporting Evidence of collection and analysis of data upon which to create an informed plan. • Data report which identifies preventable ER visits using standard methodology such as MediCal groupings, New York University groupings, or own version. • Report should identify visits for Medicaid managed care clients by Healthy Options plan,at a minimum. • Identification of the top five reasons for potentially avoidable ER visits.

8. Section 3: Strategic Plan for Prevention of Visits Creation of strategies to prevent visits • Develop at least two strategies with community partners to help patients learn in advance of arriving in the ER how to access care in less expensive location. Must include full work plan description, who, what, where, when, how. • Refrain from explicitly soliciting primary care visits to the hospital’s ER in marketing materials such as billboards, radio, scripts, etc.

9. Section 4: ER Visit Follow-Up Create strategies addressing patients who have arrived in the Emergency Department • Minimum 2 strategies with community partners addressing patients who have arrived in the Emergency Department but could be seen in less expensive location. • Describe method of identifying patients and notifying managed care organizations or their designated primary care clinics of the client’s use of the ER in a timely way, either in-place or in process of implementation.

10. Section 5: Participation in Continuing Education • Evidence of at least one hospital team member attending educational programs by the state, such as web conference for CEOs, ER Directors and key administrators or an in-person meeting on best practices.

11. Submission Process • Use Plan Template or Word document with similar format • No more than 15 pages • Send via e-mail to MedicaidQualityIncentive@dshs.wa.gov • Hospital plans will be posted for the public via Medicaid’s news website at http://hrsa.dshs.wa.gov/News/index.htm

12. Emergency Department Alternative Care Grant • Washington State DSHS/MPA • Funded by CMS • 1 of 20 State Successful Bidders • 2 years of grant funding • $1,963,581 grant • To establish Alternative Non-Emergency Service Providers or Networks of Such Providers through grants

13. COLLABORATIVE PARTNERS • Washington State Hospital Association (WSHA) • Washington Association of Community and Migrant Health Centers (WACMHC) • DSHS Research and Data Analysis Division • Dr. Fred Connell, University of Washington

14. 4 PILOTS & PARTNERS • Community Health Association of Spokane • Partner: Holy Family Hospital • Lourdes Health Network • Partners: Miramar Clinic and TriCities Community Clinic • Health Point Community Health Clinic • Auburn Regional Medical Center • Interfaith Community Health Clinic • Peace Health St. Josephs Hospital

15. INTENT OF THE PILOT • Develop and Test a variety of initiatives aimed at reducing inappropriate emergency department use among Medicaid enrollees (ME) • Connect ME with medical homes and case management services • Educate ME about the appropriate use of emergency departments and primary care • Improve access to primary care

16. PILOT STRATEGIES • 3 Required Strategies: • 24‐hour access to professional services by providing a nurse‐triage line in project communities, • Improve the ability of community health clinics (CHCs) to be effective Medical Homes and alternate emergency care providers, and • Create a case management system that is integrated with the nurse‐triage system to follow‐up on emergency department visits and connect patients with other needed services.

17. EFFECTIVE PRACTICES • Direct communication between partner sites • Sharing of information to ensure high quality medical care • Well-defined and proactive referral process • Pain management program • DSHS Patient Review and Coordination • Care coordination • Patient Advocate • Clinic/ER Liaison • Community-wide education

18. PILOT STATUS • Pilot ended on April 14, 2011 • DSHS Research and Data Analysis in collaboration with UW will be producing a pilot evaluation in July 2011 • DSHS Medicaid Purchasing Administration in partnership with WACMHC will be producing a final report on pilots in July 2011

19. More Information Thuy Hua-ly e-mail MedicaidQualityIncentive@dshs.wa.gov Washington State Hospital Association website http://www.wsha.org/0382.cfm