1. The Harris County Hospital District Program Pete Dancy, FACHE Associate Administrator Ben Taub General Hospital Houston, Texas April 3, 2008

2. Ben Taub General Hospital Level 1 Trauma Center Over 89,000 EC Visits FY 06 Lyndon B. Johnson General Hospital Level 3 Trauma Center Over 64,000 EC Visits FY 06 Harris County Hospital District (HCHD) Emergency Centers

3. EC Compression  4/1/2008 (Ben Taub)  EC diversion was implemented @ 20:32 at the request of ANM and with the approval of medicine staff. They remain open to trauma.  EC is at 144% saturation. All shock rooms are currently full with two patients waiting in the hallway on stretchers. Holding has a total of forty patients most of which are still being evaluated. All admits have beds and are being transferred without delay.

4.  Launched August 2006  Major Objectives  Shift Primary Care Related Visits to Most Appropriate Settings Provide the Right Level of Care at the Right Place at the Right Time Reduce EC Overcrowding Provide Better EC Access for True Emergencies Teach Patients About Good Use of EC Resources Find Patients a Medical Home for Primary Care RightCare

5.  Patient Presents to EC  Triaged by an EC Nurse Using a 5 Level Triage System Level 1 – cardiac arrest or immediate life-threatening Level 2 – significant trauma or manifest unstable physiology Level 3 – Require 3 or more resources (i.e. lab, x-rays, consultations, etc.)  LARGEST TRIAGE GROUP Level 4 or 5 (lower acuity) - Require none or minimal resources RightCare Process

6.  Nurse Practitioners/Physician Assistants – screen Level 4 and 5 patients Emergent – treated in EC Non-emergent patients are referred to Access/Financial Counselors/Cashiers  Patients provided service options Treat in EC Treat in Urgent Care Refer to a Community Clinic or HCHD Community Health Center If necessary, refer patient to Eligibility Office to Establish a Primary Care Medical Home RightCare Process (Continued)

7. Appropriate Patients sent To Medical Screen Is There a Medical Emergency? YES NO Patient is treated In Emergency Center RightCare EC Process

8. RightCare Program Fee Structure $150 depositBased On Eligibility $80 EC Care Urgent Care Clinic Prescriptions

9. Screened and Non-Emergent Patients

10.  Patient Referrals to Primary Care Settings  Lack of Established Eligibility  Capacity Limitations  Nurse Practitioners (Ben Taub)  Increase Utilization (UCC)  Decrease Patient Wait Times  Decrease Left Before Treatment  Frequent Fliers RightCare Challenges

11.  Increase Case Management Involvement for EC High Users (4+ Visits Month)  EC Clinical Case Managers, Social Work Case Managers, EC Nursing  Establish a process to provide prompt notification of high utilizers upon arrival  Minimize EC waiting times by quickly identifying patient issues  Navigate patients to appropriate community health program RightCare Next Steps

12.  The Right Care Program has not denied medical care to any patient experiencing a medical emergency  Education Continue Patient Education About Medical Home Target Level 3 Patients  Largest Triage Group, Use the Most Resources, Highest Left Before Treatment Group RightCare Next Steps

13. “Continuing to communicate the message to the community that emergency centers are not places where they should go for primary care is important. We have options for our patients, and RightCare gives it to them.” Dr. Thomas Granchi, Medical Director, Ginni and Richard Mithoff Trauma and Emergency Center, Ben Taub General Hospital, August 2007 Physician Perspective

14. “I knew I wanted to be seen, but they told me my wait in the emergency center might be long, so I opted for the Urgent Care Center. The service was quick, and they also told me how I could go to a community clinic for follow-up.” Urgent Care Center Patient, Ben Taub General Hospital, August 2007 Patient Perspective

15. Questions