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Reducing Inappropriate Emergency Department Use in Utah. Kevin McCulley Association for Utah Community Health (AUCH) Nancy Cheeney Utah DOH, Health Care Financing Bureau of Managed Health Care. Defining.

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Reducing inappropriate emergency department use in utah l.jpg

Reducing Inappropriate Emergency Department Use in Utah

Kevin McCulley

Association for Utah Community Health (AUCH)

Nancy Cheeney

Utah DOH, Health Care Financing

Bureau of Managed Health Care

Defining l.jpg

  • Ambulatory Care Sensitive (aka Primary Care Sensitive) emergency department visits

  • Based on a New York University algorithm that codes ED visits as:

    • Non-emergent

    • Emergent but primary care treatable

    • Emergent, ED needed but preventable/avoidable

    • Emergent, ED needed, not preventable/avoidable

    • Other (injuries, mental health, substance abuse, etc.)

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Common ACS Diagnoses

  • Bacterial Pneumonia

  • Congestive Heart Failure

  • Complications of Diabetes

  • Asthma

  • Dehydration

  • UTI

  • Chronic Obstructive Pulmonary Disease

  • Hypertension

  • Severe ENT infections

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Scope of the Problem

  • The Utah Health Data Committee found:

    • 4/10 ED visits were PCS from 2001-5

    • 58% of Medicaid enrollee visits, and 51% of uninsured ED visits were PCS in 2005

    • The largest increase in PCS visit rates was for the uninsured, from 46% to 51% between 2001-5

    • The uninsured had 21,693 PCS ED visits in 2005

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  • In the past the Bureau of Managed Health Care has conducted two other ED “studies.”

    • Mailed questionnaire in 1989

    • Face-to-face interviews in the ED in 1992

  • Study prompted policy changes

    • Tiered reimbursement for use of ED

    • Authorized Diagnoses for Emergency Department Reimbursement

    • After hours / weekend differential

      • Modified later … paid only if outside normal office hours and for existing patients only

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Emergency Room Diversion Grant

  • Goals

    • Divert Medicaid recipients from seeking treatment in the ED for non-emergent conditions

    • Educate targeted recipients on proper use of the ED through timely contacts

    • Locate primary care providers for targeted recipients

      • PCP and Urgent Care

    • Additional education for providers and staff

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Expected Outcomes

  • Decrease inefficient use of health care resources

  • Reduce non-emergent ED utilization

  • Lower overall Medicaid expenditures

  • Sustain intervention program through demonstrated savings

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Target Population

  • Initial phase

    • Develop claims surveillance tool

    • 15 – 54 year olds

    • Weber, Davis, Salt Lake and Utah counties

    • FFS and Select Access enrollees only

  • Second phase

    • Ages 15 and older as of October 2008

    • Statewide as of December 2008

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Intervention Criteria

  • Use the Utah Medicaid Authorized Diagnoses

  • Look at primary diagnosis only

  • Look at claims 2 weeks prior to surveillance date

  • FFS and Select Access only

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Changing Behavior

  • Education

    • Direct contact

      • Grant program staff

        • Phone questionnaires

      • HPR staff

      • LHD staff

      • Medical community

    • Mailed questionnaires

    • Printed educational material

    • Website

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Your PCP is a good choice

After hours / urgent care clinic could meet the medical need

Go to the nearest emergency medical facility

Yes! It’s safe to wait ...

It really shouldn’t wait too long ……………….

No, there could be death or permanent injury .………………….

Is it Safe to Wait?

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Primary Care Provider

  • Benefits

    • Knows you and your medical history

      • Not a “brand new sheet of paper”

    • Will usually work you in for a same day appointment

    • Peace of mind from knowing who to call for medical care

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Urgent Care Facilities

  • Point out the Benefits

    • No appointments

    • Lower co-pay than ED - $3.00 vs. $6.00

    • Shorter wait time to be seen

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  • Utah Department of Health, Utah Health Data Committee; “Challenges in Utah’s Health Care”; June 2007.

  • Janida Grima; Health Care and GIS Class Final Project; May 2008.

  • Association for Utah Community Health; “The Impact of Medical Homes and Access to Primary Health Care on Health Care Costs”; June 2008.