Washington State 7 Best Practices Dr. Stephen H. Anderson, MD, FACEP

The State Budget Cassie Presented at WSHA Safe Table – ER is for Emergencies 9/24/12

Problem Statement Washington State elected not to cover more than three visits off of a list of over 700+ conditions including chest pain, shortness of breath, abdominal pain, and so much more

Rationale #1 Emergency departments are filled with “non-emergent visits” that would be better treated in their PCP office. What Percentage? 8%

Rationale #2 2% Emergency Department costs are exorbitant and burden the healthcare system. What Percentage of all healthcare dollars are spent in the ED?

Rationale #3 “Emergency Physicians and hospitals have been abusing their privilege for years billing the state for non-emergent care.” Jeff Thompson, CMO of Medicaid, Seattle Times, 2/2012 What is the reimbursement for a level 1 billing by Medicaid? $12.28

Non-Emergent Conditions Defined Any condition that can wait for up to 24 hours to be seen by a provider 8% from 2009 and 2010

“Non-emergent conditions” Retrospective denials for: Chest pain Shortness of breath Hemorrhage in pregnancy Sudden loss of vision Gallstones Diverticulitis Cholecystitis Asthma COPD Sprains/Strains/Burns

Legal Issues: EMTALA Passed in 1986 Required Rep. Peter Stark, D-CA Medical Screening Evaluation to determine if an emergency medical condition exists Stabilization such that no material deterioration is likely to occur Rep. Peter Stark, D-CA

Prudent Layperson Included in the ACA in all States in 2014 Prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in a condition placing the health of the individual, or with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. RCW 48.43.005(12). Included in the ACA in all States in 2014

Parties Involved HCA WA ACEP WSHA WSMA Jeffrey Thompson Doug Porter Team of 3 WSHA WSMA

Three Visit Rule Process Legislative CMS Congress HCA Policy Regulatory Media Lay Public Patient Advocates Legal

Victories Along The Way? November 10, 2011 Stay granted by Superior Court Judge for Failure to Follow Proper Rulemaking HCA halted implementation. Prior denials halted No lost payment

Center for Medicare and Medicaid Services Met with Marilyn Tavenner, acting director of CMS Met with Steve Cha, MD, head of Medicaid “We agree with you in principle, but we prefer to have you work it out at a state level at this time”…

Return to the Table Focus on Priorities Improving health outcomes Preserving Prudent Layperson Protection & access to Emergency Services Coordinating care for the highest utilizers Meeting the State’s budget requirements

We Won! Governor Suspended Three Visit Limit policy April 1st, 2012 Moved forward with alternative plan in budget proviso on April 10th, 2012 June 15th, deadline for implementation

The Seven Best Practices Barbara Presented at WSHA Safe Table – ER is for Emergencies 9/24/12

A) Electronic Health Information Goal: Exchange patient information among Emergency Departments Identify frequent users Get access to treatment plans Use in providing care Exceptions for CAHs with financial burden Barbara TOSS TO NATHAN for explanation of how to implement

Emergency Department Information Exchange Registration to the cloud EDIE Alert with Care Plan during MSE Case Management

B) Patient Education Goal: Help patients understand and use appropriate sources of care Active distribution of educational materials WSHA/WSMA/ACEP brochure Discharge instructions Barbara --- BARABARA, continue on to how to accomplish

Not to supplant or interfere with Medical Screening Exam “The Poster” 2.0 Not to supplant or interfere with Medical Screening Exam

What about my Press-Gainey Scores? Warning What about my Press-Gainey Scores?

C) Patients Requiring Coordination (PRC) “Superutilizers” Goal: Ensure hospitals know when they are treating a PRC patient and treat accordingly PRC clients = frequent ER users, MOST VULNERABLE. 80% concomitant mental health & drug & alcohol issues Receive and use client list Identify patients on arrival Develop and coordinate case management programs Use care plans Barbara TOSS TO NATHAN

D&E) PRC Client Care Plans and Follow up Goal: Assist PRC clients with their care plans Contact the PCP on arrival Appointment within 72 hours when appropriate If not needed, notify PCP of visit Relay barriers to care All clients: 3-4% 1-2% Barbara TOSS TO NATHAN

ED Care Plan Standard Header Information Security Alert Date Plan First Created Date Plan Last Updated Security Alert Pain Contract and Scheduled Prescribing Security Alert: Information regarding the safety of ED staff near the patient including the patient’s verbal/physical aggression. This will include theft from the ED or the patient’s history of destroying hospital property or disturbing other patients. If a specific type of ED room, such a seclusion room or single room, is recommended for the above reasons this will be included. “This patient often yells profanity at ED staff and has thrown medical equipment when denied opioids. Recommend having hospital security constantly observing the patient and the patient placed in a single ED exam room separated from other patients if medically appropriate.” Pain Contract and Scheduled Prescribing: A statement that the patient is on a pain agreement including the provider. A statement that the patient receives monthly prescribing of controlled substances including the dose, quantity and prescriber. “The patient is on a pain agreement with Dr. Marcus Welby at the Welby Clinic in Mayberry, WA. Dr. Welby prescribes the patient 60 tablets of hydrocodone 5/325 and 60 tables of 1 mg Ativan a month.”

ED Care Plan Standard Primary Care Provider and Specialist Past Medical and Surgical History Substance Use and Abuse History Mental Health Conditions Primary Care Provider and Specialist A listing of the patient’s primary care provider and the clinic name with the phone number in addition to a listing of the patient’s relevant medical specialists with clinic and phone number. “The patient is seen for primary care at the Welby Clinic (555-555-5555) by Dr. Marcus Welby. Please copy this provider on all dictation. The patient also sees Dr. Smith at Smith Pain Clinic (555-555-5555).” Past Medical and Surgical History A listing of the patient’s relevant past medical and surgical history. If the patient is known to have obstructive sleep apnea or obesity this will be listed as a risk for respiratory depression from opioids. A listing of the anatomical location of the patient’s chronic pain with the duration the condition has been present. “Congestive Heart Failure, diabetes, chronic back pain, lumbar fusion, appendectomy.” Substance Use and Abuse History A statement about controlled substances the patient may have abused or received medical (withdrawal) or rehabilitative treatment for. A statement about efforts that have been attempted for the patient to obtain needed substance abuse treatment. Specifically address alcohol use. “The patient has a history a heroin addiction and has refused to have a chemical dependency evaluation performed in order to enter a treatment program. Encourage the patient to have a chemical dependency evaluation performed at the CDP Evaluation Center by calling 555-555-5555. The patient has also admitted to abuse Vicodin when seen in the Valley ED on 3-25-2012.” Mental Health Conditions A listing of the patient’s mental health conditions and providers and relevant psychotropic medications. “The patient has a history of schizophrenia and is seen at Big County Mental Clinic by psychiatrist Dr. Mind and counselor Diane Relax and case manager Carry Comfort at 555-555-5555. The patient takes Olanzapine 10mg PO daily for schizophrenia and is on a least restrictive alternative that requires him to take his medication. At baseline the base is mildly disorganized.”

Care Plan Standard Optional (Phase 2) Optional sections, may be made mandatory later. Barriers to Care Delivery Radiation Alert Overdose Alert Special Care Recommendation Details Barriers to Care Delivery Behaviors of the patient that have prevented them from obtaining appropriate care including doctor shopping, addiction, refuses to see a primary care provider, or failure to complete a Medicaid application. The ED provider should reinforce to the patient correcting these behaviors on each ED visit. “The patient refuses to complete a Medical application and does not attend appointments with his PCP. He is also non-compliant with his medication” Radiation Alert A statement about which is subjectively considered to be an excessive amount of radiation exposure from imaging. Preferably at statement summarizing if most of the imaging has been negative or the pertinent positive finding from the imaging. “The patient has a history of 8 abdominal/pelvis CT scans in one year looking for kidney stones and none of them have shown kidney stones in the ureters only calcifications of the kidney.” Overdose Alert A statement regarding the patient’s history of overdose or attempted overdose. A history of overdose places a patient at high risk for subsequent overdose which should influence the ED provider’s decision to prescribe controlled substances. “The patient overdosed on hydrocodone/acetaminophen on 3-25-2012 at Valley Hospital and required Naloxone administration.” Special Care Recommendation A recommendation for how a condition should be treated or has been successfully treated in the past. For example describing a specific non-opioid regime that has been used successfully for a patient with migraines headache. This section can also be used to describe medication treatment for rare medical disorders such as hemophilia, congenital heart defects, metabolic diseases, arrhythmias, and genetic disorders of children to name only a few. Details This section contains relevant detailed information that is useful for the ED provider to provide care and differentiate new conditions from stable conditions. Sometimes a brief narrative is the best way to convene the patient’s background and this section is reserved any detailed background information. Consider listing identifying tattoos and alibis. A statement that the ED care plan should supersede other care plans that may exist if relevant. The goal should be that the entire care plan fits on one page for a page without unusual circumstance. This section can include incongruous urine toxicology screens that can be. “The patient is often homeless and presents only on the coldest nights often requesting a sandwich. She is very knowledgeable of local homeless shelters but prefers the free sandwiches and access to a television the ED provides. Her children were removed from child protective services and the patient is on probation. Several attempts to find the patient housing have failed because the patient refuses to complete the paperwork.”

F) Prescription Monitoring Goal: Ensure coordination of prescription drug prescribing practices Enroll providers in Prescription Monitoring Program: electronic online database with data on patients prescribed controlled substances Target enrollment for ER providers : 75% by June 15, 2012 90% by December 31, 2012 Barbara TOSS TO STEVE

Prescription Monitoring Programs Game Changer 49 out of 50 states have this, largest network shares across 25 states In WA, 96% of ED providers registered “REGISTERED” does not equal “USES” ACEP against mandated use… but imagine Push not Pull, No Bias, part of the EDIE

G) Use of Feedback Information Goal: Review reports, ensure interventions are working Designate ER leader and quality manager to receive, review, and act on utilization management reports Involve executive-level leadership Barbara TOSS TO NATHAN to talk about the ED Work Group

Decrease in ED Prescriptions per month written to PRC Clients in One Hospital

“Dr. Feel-good” Vs. “Grumpy” Find the Best Practice 6 Vs. 108, Pills per shift ?

In God we Trust…. All others Bring Data!

Reduced ED visits by 9.9% Dr. Steve Anderson Now for the exciting results – Claims data from both fee-for-service and managed care Medicaid clients’ emergency department utilization was analyzed to examine ED utilization, frequent visitor utilization, visits resulting in a scheduled drug prescription, and visits with a low acuity diagnosis. Before the formal implementation of the best practices (June 2012) and the most current available month of data (June 2013), all measures show a decline The rate of emergency department visits declined by 9.9%

Reduced number of visits by frequent clients by 10.7 % Dr. Steven Anderson As you can see, we’ve achieved a more than 10 percent reduction in emergency department visits by Medicaid patients with five or more visits. These patients are often the most complex and the most expensive.

Reduced visits resulting in a narcotic prescription by 24% We have also reduced the rate of visits resulting in a scheduled drug prescription decreased by 24.0%, which means more patients are not receiving narcotics through the emergency department.

What does that mean for patients? MVA Vs. Overdose Deaths Overdose Deaths in WA State

Reduced low-acuity visits by 14.2% Steve Anderson We’ve also seen a decrease in the rate of visits with a low acuity diagnosis decreased by 14.2% This means fewer patients who could seek care in either an urgent care or primary care clinic are not coming to the emergency room. This trend is good for the patient and good for lowering health care costs. HAND OFF TO Dr. Dan Lessler

Savings of $33.65 million were achieved. Dr. Dan Lessler (INTRODUCE YOURSELF) The implementation of the ED best practices is not only improving care for patients, it is saving dollars for the state. HCA will be working with all partners and stakeholders to sustain and extend these efforts. We can clearly see that the program is having an impact on patients’ lives in the reduced number of emergency room visits and improved coordination of care. This in turn has lowered ED costs. In fact, the anticipated savings identified in the Third Engrossed Substitute House Bill 2127 in 2012 from implementing the 7 best practices were prospectively built into the premiums paid to managed health care plans. Thus, savings of $33.65 million were achieved in reductions to the Health Care Authority’s budget. While all of the savings that were built into (and achieved) in the Health Care Authority budget cannot be directly related to the implementation of the 7 best practices, it is clear that the overall goal of reducing emergency room expenses has been achieved.

What Did We Learn As Doctors? Advocacy is a process Relationships are critical Teamwork is more effective Can be difficult Temptation can be the enemy

My Time As Chapter President Find your Allies Focus on your Priorities Believe in Win-Win

Questions?