Washington State Best Practices Update Fall 2012 Dr. Stephen H. Anderson, MD, FACEP Dr. Nathan Schlicher, MD, JD, FACEP Dr. Darin Nevin, MD Presented at WSHA Safe Table – ER is for Emergencies 9/24/12

The State Budget 2 Presented at WSHA Safe Table – ER is for Emergencies 9/24/12

Health Care Portability Act of 1996 You have the right to access emergency services 24 hours a day. By law, a situation is considered to be an "emergency" if a prudent layperson believes that failing to act immediately would put your health or the health of others in danger. 3 Both State & Federal legislative protection for insured & managed care patients… Presented at WSHA Safe Table – ER is for Emergencies 9/24/12

4 The Seven Best Practices 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 5 Presented at WSHA Safe Table – ER is for Emergencies 9/24/12

B) Patient Education Goal: Help patients understand and use appropriate sources of care Active distribution of educational materials WSHA/WSMA/ACEP brochure Discharge instructions 6 Presented at WSHA Safe Table – ER is for Emergencies 9/24/12

C) Patients Requiring Coordination (PRC) Information Goal: Ensure hospitals know when they are treating a PRC patient and treat accordingly PRC clients = frequent ER users, often narcotic seekers Receive and use client list Identify patients on arrival Develop and coordinate case management programs Use care plans 7 Presented at WSHA Safe Table – ER is for Emergencies 9/24/12

D) PRC Client Care Plans Goal: Assist PRC clients with their care plans Contact the primary care provider when PRC client visits the ER Efforts to make an appointment with the primary care provider within 72 hours when appropriate If no appointment required, notify primary care provider that a visit occurred Relay barriers to care to Health Care Authority 8 Presented at WSHA Safe Table – ER is for Emergencies 9/24/12

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 – Enroll is one thing… USE is another! 9 Presented at WSHA Safe Table – ER is for Emergencies 9/24/12

G) Use of Feedback Information Goal: Review reports, ensure interventions are working Report specified information to Health Care Authority Designate ER leader and quality manager to receive, review, and act on utilization management reports Involve executive-level leadership 10 Presented at WSHA Safe Table – ER is for Emergencies 9/24/12

Managing Difficult Conversations Social Psychology 201 For ED’s Stephen H. Anderson M.D., FACEP President, WA State Chapter ACEP Presented at WSHA Safe Table – ER is for Emergencies 9/24/12 11

I Think You Have A Drug/ Alcohol Problem Society/ Legislature/ Peers now tell us We MUST have these conversations THIS is the pivotal time. Presented at WSHA Safe Table – ER is for Emergencies 9/24/12 12

Drug & Alcohol Problems The Principles There are rules/ guidelines Listen first Your allies/ their allies “Their support” might turn out to be your best ally!” WIN-WIN Be true to yourself Presented at WSHA Safe Table – ER is for Emergencies 9/24/12 13

Drug & Alcohol Tools to Help Old Records EDIE WA state Prescription Monitoring Program Educate patients that these exist Presented at WSHA Safe Table – ER is for Emergencies 9/24/12 14

I Think You’re Here Too Often PRC Patients Requiring Co-ordination Presented at WSHA Safe Table – ER is for Emergencies 9/24/12 15

You’re Here Too Often New WA Hospital Requirements Identify PRC clients upfront Notify their PCP of visit Discharge patient with instructions along: “the right patient-to the right place-at the right time” Shouldn’t be a punitive discussion Presented at WSHA Safe Table – ER is for Emergencies 9/24/12 16

Warning! Presented at WSHA Safe Table – ER is for Emergencies 9/24/12 17

Nathan Schlicher, MD, JD Legislative Affairs Chairman, WA ACEP Associate Director, St. Joseph’s MC ED Associate Director, TeamHealth PSO Presented at WSHA Safe Table – ER is for Emergencies 9/24/12 18

 All State ED Visits Presented at WSHA Safe Table – ER is for Emergencies 9/24/12 19

 SJMC Medicaid Visits Presented at WSHA Safe Table – ER is for Emergencies 9/24/12 20

 PRC Visits with Narcotics Presented at WSHA Safe Table – ER is for Emergencies 9/24/12 21

 Average Pills per Script Presented at WSHA Safe Table – ER is for Emergencies 9/24/12 22

 Pills per Script Presented at WSHA Safe Table – ER is for Emergencies 9/24/12 23

  We are doing well overall  One of the best on pills per scripts  Room to improve on PRC folks  Fewer narcotics  State improving, must continue to climb Takeaway Points Presented at WSHA Safe Table – ER is for Emergencies 9/24/12 24

Darin Neven, MS, MD Providence Sacred Heart Medical Center and Children’s Hospital Spokane, WA

 Draft ED Care Plan Standard  Header Information – Date Plan First Created – Date Plan Last Updated  Security Alert  Pain Contract and Scheduled Prescribing

 Draft ED Care Plan Standard  Primary Care Provider and Specialist Past Medical and Surgical History Substance Use and Abuse History Mental Health Conditions

 Optional (Phase 2)  Optional sections, may be made mandatory later. Barriers to Care Delivery Radiation Alert Overdose Alert Special Care Recommendation Details

 New Initiatives  Protect Providers from False Complaints  Prescribed Naloxone 

Best Practices Are a Foundation If we are serious about achieving this: Hospitals and emergency physicians need to be looking for trends and patterns, intervene, make continuous change! Projection Actual trend Presented at WSHA Safe Table – ER is for Emergencies 9/24/12 25

Best Practices 2.0 ? Access to follow-up primary care Access to dental health care Reimbursement incentives for same day scheduling of PRC clients Accountability to Health Care Systems for coordination of care Persistent pressure for Tort reform to decrease costs of “defensive medicine” Presented at WSHA Safe Table – ER is for Emergencies 9/24/12 26

(13) Client financial responsibility ” A client placed in the PRC program may be billed by a provider and held financially responsible for health care services when the client obtains non-emergent services and the provider who renders the services is not assigned or referred under the PRC program.” BEWARE! Newest Twist in HCA rules, July 2012 Presented at WSHA Safe Table – ER is for Emergencies 9/24/12 27

Questions? 28