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Barb Simons, RN Cate Ranheim, MD October 2010. Madison, WI. Overview :. The Need The Program The Patients The Analysis. Defining the Needs for a Solution: . PATIENTS: ED is not the right care for increasing chronic care management needs CLINICIANS: under or over-treating ED patients

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Barb Simons, RN

Cate Ranheim, MD

October 2010

Madison, WI

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  • The Need

  • The Program

  • The Patients

  • The Analysis

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Defining the Needs for a Solution:

  • PATIENTS: ED is not the right care for increasing chronic care management needs

  • CLINICIANS: under or over-treating ED patients

  • PAYORS: insurance premiums rise in response to hospitals increasing costs to cover bad debt and uncompensated care

  • HOSPITAL: capacity constraints in ED require targeting avoidable ED admissions

    • we began with those who, upon intake, stated homelessness, provided shelter addresses, or did not give an address

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Overcoming Barriers to Good Health in the Medically Underserved

  • Retrospective, medical record review

  • 330 homeless and unstably housed patients in MADISON, WI seen in ED or hospitalized at Meriter Hospital between 1/07-10/08

  • manually reviewed to identify and evaluate barriers to good health:

    -Housing -Literacy

    -Lack of primary care provider -Transportation

    -AODA -Medications

    -Mental Illness - Insurance

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Where Should We Focus Our Resources? Underserved


Lack of primary care provider


Mental Illness*





*Each identified in 15% of population

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HEALTH Patients Meriter Medical Record Numbers Underserved

Program patients sought Meriter emergency services 138 times in the 10 months before the program started.

Over $86K COST savings potential from these visits alone*.

*Based on Medicaid reimbursement for ED visits of $0.13/$1.00 charge

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November 2009 Underserved

Helping Educate and Link the Homeless (HEALTH) Program is born:

  • Four outreach locations open in an effort to overcome identified barriers to good health

  • One outreach clinic/week, four alternating sites, volunteer-staffed

  • Funded with $250,000 grant from Meriter Foundation for 2010

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The “Hut” Underserved

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HEALTH Volunteers Underserved

Facility, 22


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HEALTH Volunteer Hours UnderservedJan-Sept 2010

~ 718 hours


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HEALTH Volunteer Hours (Estimated Value) UnderservedJan-Sept 2010

~ $25,000*


* Madison market -based

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HEALTH Program Donations Underserved




*Direct expenses only: value of HEALTH Hut building or utilities not included

**Time frame = 6 months

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The Patients Underserved

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n=185 Underserved

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HEALTH Patients UnderservedHousing Status

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HEALTH Patients UnderservedPayer Status

/No Coverage

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HEALTH Program Data Underserved

  • Program patients Nov 2009 – Aug 2010

  • 185 unique patients

    393 visits

















1% unknown

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HEALTH Patients UnderservedMedical Diagnoses by Bucket

  • Most cardiorespiratory patients have a secondary cardiorespiratory diagnosis

  • Mental Illness: secondary diagnosis prevalence is only 2% higher than primary diagnosis prevalence

Secondary Diagnosis Group

Primary Diagnosis Group

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HEALTH Patients Underserved



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HEALTH Patients UnderservedNumber of “Hut” Visits per Patient

Total Visits: 393

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The Analysis Underserved

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HEALTH Patient Patterns Underserved

  • Top 5 diagnoses represent just 22% of all diagnoses:

    Hypertension, Depression, Anxiety, Type II Diabetes

  • Transitionally-housed patients made more repeat visits to the Hut per person, on average, than those reported as homeless or permanently housed.

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Patient Pathways Underserved

Value: avoiding unnecessary ED visits, reducing need for I/P admissions

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Where do the underserved go for care? Underserved

Control Group

HEALTH Program Participants


C, D




A, B









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Measuring Value Underserved

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How It Works Underserved

Costs = total direct expenses only (salaries, supplies, bus passes, equipment) and excludes building depreciation, overhead, etc.

Average Inpatient cost of care is specific to diagnosis bucket (i.e., Service Line)

The greater the ALOS and Median Inpatient Cost of Care the greater the avoided cost opportunity: analyze your current volumes to estimate your potential savings

*all patient and cost data listed here is fictitious

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Quick and Dirty ROI Recipe Underserved

1. Gather ingredients from Finance Department:

  • Cost per Medicaid ED visit: (total direct costs *Medicaid % payor mix)/N Medicaid patients

  • Number of ED admits from either local shelters or no address in one year: assess common ED diagnoses by service line

  • Average I/P costs = total direct expenses for Service Line/N patients (use 1 year of data at least)

    2. Calculate your current costs for these patients to date using the above data

    3. Use the formula presented to determine your cost reduction potential

    • Sample at least 30 patients: estimate probability of ED avoidance through record review

    • Use Elixhauser comorbidity values (see supplemental)

    • Assume a indigent care program estimated cost per patient: we used $50

      4. If the cost of program startup – donations is less than #3, consider implementing an off-site indigent care program like HEALTH.

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Thank you to our donors! Underserved

Meriter Foundation

St. Vincent de Paul

UCC-Memorial Church

Meriter Hospital

Masimo Corporation

Association of Spiritual Caregivers

Wisconsin Medical Project

Dr. Bernie Micke

Dr. Jack Kenney

Nicole Heide, RN

Mandy McGowan, RN

McGovern & Sons

Jo Hoffman/Ellen Boyce

John Warden

Home Depot

Hometown Flooring


Meriter Medical Staff Office

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A special thank you to our friends and colleagues, Heidi Kimble and

Melissa Strayer, for data analysis and volunteer time!

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Supplemental B: Elixhauser Comorbidity Index Kimble and

Source: Effects of Specific Comorbidities on Outcomes Controlling for Demographic, Insurance, and Other Clinical Factors of Adult, Nonmaternal Patients Who Were Hospitalized in California in 1992 (n = 1,779,167)

Elixhauser, Anne; Steiner, Claudia; MD, MPH; Harris, D; Coffey, Rosanna. Comorbidity Measures for Use with Administrative Data.

Medical Care. 36(1):8-27, January 1998.