Florida Emergency Department Collaborative Results of ED Utilization Analysis and Initiatives Questionnaire June 8, 2011 Presented by: Howard Pitluk, MD, MPH, FACS, Vice President/Chief Medical Officer Margaret deHesse, RN, BSN, Executive Director State and Corporate Services

Plans Who Provided Data HMOPSN Humana, Inc.Sunshine State Health Plan Medica Health Plans of FloridaFirst Coast Advantage Better Health, LLCSouth Florida Community Care Network Molina Healthcare of FloridaChildren’s Medical Services Network Duval Freedom Health (Freedom 1 st )Children’s Medical Services Network Broward UnitedHealthcare Community Plan Universal Health Care

ED Utilization Analysis 11 out of 12 plans conducted an Emergency Department utilization analysis

When was the Analysis Completed?

Did the analysis include identification of visits to the ED that could have been treated by the PCP? Yes No None of the plans used the New York University (NYU) Algorithm for the ED analysis

Medica - HMOUniversalSunshine - HMOSouth Florida - PSNCMS Duval - PSN URIXXXX Viral SyndromeXX Sore ThroatX Croup/CoughXXX Otitis MediaXXX GastroenteritisXX AsthmaXX Low Back PainX DentalXXX FeverXXX PharyngitisXX Abdominal PainXX UTIXX VomitingXX Ear PainX RashX ConjunctivitisX ConstipationX Allergic RhinitisX Insect BiteX Top Conditions of Avoidable ED Visits

Observations of ED Analysis by HMOs/PSNs  A small percentage of members account for a high percentage of ED use (ultra utilizers)  Majority of visits for members < 21 years of age  Majority of visits for members 0-5 years of age

Did the Analysis Identify Ultra Utilizers?

Conditions of the Ultra Utilizers Each of the following conditions was identified as a Top Ten Condition of Ultra Utilizers by just one plan: Sickle Cell DiseaseBehavioral Health Issues Abdominal PainGastroenteritis/Colitis URIOtitis MediaFeverDiarrhea Chest PainObstetricalOrthopedicToothache DiabetesSpinal StenosisDigestiveViral Infection RashSore ThroatBronchitisHeadache Head InjuryUTISymptoms, Signs, and Ill defined conditions Diseases of the Nervous System and Sense Organs Each of the following was identified once by the plans as a Top Ten diagnoses of the Ultra Utilizers

 Member Education and Outreach – Welcome packets - Location of urgent care centers Use of 24/7 nurse line Reminder letter to schedule appointment with PCP Educational materials on ED use Encourage linkage to PCP Assist member with changing PCPs Current Initiatives

 Case Manager/Health Coach - High utilizers – Refer to case/disease management Assist members with scheduling PCP appointments Behavioral health co-management Health coach – Real time follow-up  Provider Education and Outreach – Educate providers about urgent care options Notification of member ED use Notification of high opiate use Current Initiatives

 Emergency Department Daily/ Weekly ED Census Work with ED Staff to conduct a face-to-face meeting with member and perform an ED assessment Current Initiatives

 Sunshine State – 90 percent of members stopped going to the ER 10 percent still use multiple times Greater than 40 percent decrease in ER usage overall  Universal - Results showed a decrease in ED usage for the pilot county Current Initiatives - Evaluation

 Humana - Pre-evaluation ED usage of the entire population Post evaluation usage Pre-evaluation of members who had interventions Post intervention Current Initiatives - Evaluation

Daily Census from EDs

Methods of Receiving Census TypeNameMethod HMOSunshine StateFax HMOHumanaN/A HMOMedicaN/A HMOUnitedHealthcareFax HMOFreedom Health-Freedom 1stN/A HMOMolina HealthcareN/A PSNBetter Health LLCMethod unknown PSNCMSN BrowardSelf-run report PSNCMS DuvalN/A PSNFirst Coast AdvantageHospitals and fax daily ED census PSNSouth Florida Community CareSelf-run report

24/7 Nurse Advice Line Health Plans

4 HMO/PSNs have a 24/7 Nurse Advice Line for members Nurse Advice Line Usage TypePlanUsage HMO Sunshine StateLess than 1% HMO HumanaNot sure of exact percentage but it is probably low HMO MedicaN/A HMO UnitedHealthcareNo response HMO Freedom Health-Freedom 1stN/A HMO Molina HealthcareLess than 5% HMO UniversalNo response PSN Better Health LLCNo response PSN CMSN BrowardN/A PSN CMSN Duval1% (Behavioral Health only) PSN First Coast AdvantageN/A PSN South Florida Community CareN/A

Care from Non-PAR Providers Type PlanResponse HMO Sunshine State HPLess than 1% HMO HumanaNot known but probably low HMO Medica6.1% (285 members) HMO UnitedHealthcareUnknown HMO Freedom Health-Freedom 1stUnknown HMO Molina HealthcareLess than 5% HMO UniversalUnknown PSN Better Health LLCMinority of members PSN CMSN Broward20% PSN CMSN Duval7.90% PSN South Florida Community Care20% PSN First Coast Advantage32.7 %

 Member - Need member education on treating minor ailments Real time outreach is effective High illiteracy rate - welcome packets of little benefit  ED - Lack of communication between EDs EDs advertise low wait time Considerations for the ED Collaborative

 Other Use mobile diagnostic units for preventive services High volume of ED use at non-contracted facilities No link between mental health vendor and MCP regarding ED use driven by mental, alcohol and substance abuse disorders Underlying diagnoses in children often make ED visits the correct choice 21 Considerations for the ED Collaborative

How are members with Behavioral Health conditions who access the ED tracked? 22 Behavioral Health

A Look at Ohio’s Statewide ED Collaborative 23

24  Structure Statewide Collaborative (IMPROVE) Five Regional Steering Committees  Patient Streams Ultra Utilizers: Mental Health, Non-mental Health, Chronic Back Pain Dental URI - Statewide Overview

25  High utilizers are identified as sample members.  Interdisciplinary Teams develop care treatment plans to establish a coordinated care approach. The goal is to meet the sample members’ needs and re-direct them to their medical home rather than the ED.  Sample members are flagged at participating EDs.  If a member in the sample accesses the ED, the attending ED Physician will:  Reference the care plan summary, and  Notify the Interdisciplinary Team contact person that a sample member has accessed the ED.  The Interdisciplinary Team continually outreaches sample members and coordinates care to reduce avoidable ED visits. Ultra Utilizers Intervention

Buckeye (5 Sample Patients) Case Managers Care Source (5 Sample Patients) Case Managers Unison (3 Sample Patients) Case Managers Mercy St. Vincent [ED] Toledo Hospital [ED] University of Toledo [ED] NORTHWEST REGION – BACK PAIN TEST SITES T OTAL PATIENTS IN TEST INTERVENTION = 13 Mercy St Vincent Pain Clinic Care Treatment Plan Emergency Departments Contact: Clinic Manager 26 Integrated Care Team Managed Care Plans (MCPs)

27 Business Hours  Medicaid managed care members presenting with dental conditions are identified at the ED.  EDs call participating dental providers and secure a fast-tracked dental appointment for the patient.  EDs forward the identifying information of sample patients to the appropriate MCP.  MCPs follow-up with the member. After-Hours  ED staff distribute a card listing the MCP contact information and instruct the patient to call the MCP during business hours for a fast- tracked dental appointment. Dental Intervention

28 1.Sample members receive a kit for colds which promotes the managed care plans’ (MCP) 24-Hour Nurse Advice Line with a “call early, call often” theme Most sample patients receive the kits through the mail with a letter from their primary care physician (PCP) or their health plans’ medical director. In the real-time test interventions, kits are distributed at the ED. 2.MCP Nurse Advice Lines triage sample members and bridge services the MCP has to offer with follow-up PCP care 3.PCP office provides next day/same day appointment scheduling for sample members 4.An MCP Health Coach follows-up with members in the test intervention sample URI Intervention

Questions 29