Maximizing Efficiency and Productivity in Your Rural ER. Bruce Penner, RN David D. Luehr, MD

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1 Maximizing Efficiency and Productivity in Your Rural ER Bruce Penner, RN David D. Luehr, MD

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4 Can we afford to continue as we are? What if your ER had to pay for itself? What if you were rated on patient outcomes?

5 Triple Aim Improving Patient Experience (quality and satisfaction) Improving Population Health Reducing Cost

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7 The Patient s Perspective (and maybe ours) Hospitals (ER, Out Pt, In Pt) Clinics

8 The Patient s Other Perspective Hospitals (ER, Out Pt, In Pt)

9 The Other Patient s Other Perspective Emergency Dept.

10 Putting Priorities in Order Reduce Cost Improve Outcomes/Quality Justify Cost with Improved Outcomes/Quality

11 Clinical Integration ER Clinics

12 Clinical Alignment ER Pt. Clinics

13 Clinical Integration: Collaboration among different health care providers and sites to ensure higher quality, better coordinated and more efficient services for patients.

14 Clinical Alignment: A patient centered process that addresses acute and chronic illness across a care continuum. It recognizes and puts the true needs of the patient first and works with others in the care continuum to meet those needs by encouraging the right care be given in the right place at the right time.

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16 What We Prepare For

17 What We Do Most Often

18 136.1 million ER visits in million arrived by ambulance 116 million arrived by other means 43% of hospital admissions start in ER

19 CDC: Top Three Reasons for Visits (2007) Superficial injuries Contusions, sprains and strains Upper respiratory infections

20 Top Ten Reasons for Visits Discovery Health Chest pain/sob Belly pain Toothache Sprains, strains, fractures Colds (URI) Cuts, bruises Back pain Skin problems, rashes, infections Foreign bodies Headaches

21 Depending on the severity of the pain or condition, 9 out 10 of the top medical reasons people go to an ER for are routinely addressed in the primary care setting. If we are doing that much primary care in the ER are we doing that much primary care in the ER?

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23 Adults (18-64), ER w/in 12 Months, Not Admitted.

24 Adults (18-64), ER w/in 12 Months, Not Admitted.

25 Who s Paying the Bill? Private insurance: 54 percent Medicare: about 38 percent Medicaid: about 33 percent Uninsured patients: 35 percent 46% is self pay or government paid

26 Pulling all that data together, researchers found that the average charge for an emergency room trip came out to $1,233, which is 40 percent higher than the average American rent...$871 per month.

27 Current Payment Reforms Coming from all payers Total Cost of Care (TCOC) ACO Risk Sharing: up and down All are focused on reducing cost in all areas while improving quality of care.

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29 $400 $350 $300 $250 $200 $150 $100 $50 $0 $89 $97 Primary Care Clinic Allergies Urgent Care $345 Emergency Department

30 $700 $600 $500 $400 $300 $200 $100 $0 $89 Primary Care Clinic Bronchitis, Acute $127 Urgent Care $595 Emergency Department

31 $700 $600 $500 $400 $300 $200 $100 $0 $85 Primary Care Clinic Bronchitis, Chronic $114 Urgent Care $665 Emergency Department

32 $450 $400 $350 $300 $250 $200 $150 $100 $50 $0 $81 Primary Care Clinic Earache $110 Urgent Care $400 Emergency Department

33 $600 $500 $400 $300 $200 $100 Pharyngitis $98 $94 $525 $0 Primary Care Clinic Urgent Care Emergency Department

34 $400 Pink Eye $370 $350 $300 $250 $200 $150 $100 $76 $102 $50 $0 Primary Care Clinic Urgent Care Emergency Department

35 $700 $600 Sinusitis $617 $500 $400 $300 $200 $100 $85 $112 $0 Primary Care Clinic Urgent Care Emergency Department

36 $600 $500 $400 $300 Strep Throat $531 $200 $100 $93 $123 $0 Primary Care Clinic Urgent Care Emergency Department

37 $600 $500 $400 $300 Upper Respiratory Infection $486 $200 $100 $83 $111 $0 Primary Care Clinic Urgent Care Emergency Department

38 Cost Disparity Urgent Care 21% more than PCC ER Care 499% more than PCC

39 How much does care cost in an ER?

40 How much does it cost an ER to give care?

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42 Putting Priorities in Order Reduce Cost Improve Outcomes/Quality Justify Cost with Improved Outcomes/Quality

43 Quality Evidence Based Medicine and Excellent Customer Service Never Goes Out of Style!

44 Types of Quality Clinical Quality clinical care that is measurably superior by recognized standards. Service Excellence - meeting the needs and fulfilling the expectations of patients and staff. Operational Efficiency doing both of the above efficiently without time/resource waste.

45 45 E&M Code Distributions Actual % MN Ave % CC

46 Revenue Differential Actual Revenue $2,659,810 Average Revenue $4,441,23 Lost Revenue $1,781,429

47 Key Attributes of an Efficient ED Be Decisive Stay Focused Make use of any down time Take charts out of order D/C first Admit immediately

48 Patients should leave the ED with a primary care appointment and get a f/u call to confirm it.

49 Post Visit Calls Post visit calls reduce the likelihood of bounce backs and readmissions! Patient satisfaction is doubled with follow up calls. 58% -> 95%)

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51 Cooperation is key to both the present and the future

52 Team Triage & Team Based Care

53 ER/Primary Care Clinical Alignment Building a Care Continuum

54 Identify and Treat Chronic Illness in ER Example: Patient has been seen multiple times in ED with elevated BP each time. Dx. of HTN Start Med Refer to PCC Make Appt.

55 Identify and Treat Chronic Illness in ER Example: Patient presents with asthma exacerbation. Use ACT/C-ACT (asthma control test) Can be done by nurse Asthma Action Plan completed Reinforce need for PCC follow up Make appointment if possible

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58 Treat ED visit as a consult, not just an emergency. Consult notes sent to primary care physician Clear and concise communication between physicians Pre-developed tools/forms/methods Maximize opportunities of interoperability (EHR)

59 Use common terms in ER and clinic to improve patient engagement/adherence.

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61 Use standard patient education material in ER and clinic.

62 Use motivational interviewing technique in ER. Open ended questions Affirmations Reflections Summarizing Easily learned and easily usable by all ER staff.

63 Use motivational interviewing technique in ER. You ve heard from many healthcare providers that you should quit smoking. How do you think you can motivate yourself to change? Easily learned and easily usable by all ER staff.

64 Use motivational interviewing technique in ER. You ve quit for two days!. Think of all you ve learned about succeeding at that attempt. Easily learned and easily usable by all ER staff.

65 Recognize and utilize non-physician staff up to their full level of license. Nurses as team members. Maximize their responsibility and role.

66 Collaborate (ER, primary care and specialty physicians) to develop protocols/guidelines. Consider high cost or high complexity conditions. Simple and concise What needs to be done? Medical necessity-first priority. What doesn t need to be done? Where are clear trigger points for referral or transfer? Treating the patient vs. treating litigation potential. Imaging, lab, etc.

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69 Collaboration with ER staff and clinic staff. ER nurse participating on Health Care Home (Medical Home) care teams. Patient specific (5%/50%) Condition specific(? %) Asthma, diabetes, depression

70 On-site or on-call social worker/mental health provider. Ex: Patient given PHQ 2 or PHQ 9 in ER for depression screening

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72 PHQ-9

73 Patient scores positive (high potential for depression) from PHQ 2 and/or PHQ9 Warm Handoff to SS Make Appt. with PCC SS Follow up

74 Social issues drive overutilization and nonadherence as much or more than medical issues.

75 Emergency departments play and will continue to play a very major and a very important role in healthcare. They are not exempt from the obligations addressed in the Triple Aim; moreover, they are critical to achieving these goals and helping clinics demonstrate quality care as in the Minnesota Community Measurement.

76 Increased and improved patient focused collaboration between primary care and emergency care will not only improve the care given but will make obvious the value and worth of emergency departments within the healthcare delivery process.

77 Thoughts and Questions?