Program targets ED use for non-urgent conditions
Patients educated on other options
When members of Passport Health Plan use the emergency department for non-urgent conditions, the health plan calls them to find out why they chose that level of care.
"We're trying to get a handle on why members go to the emergency department as opposed to the primary care provider or urgent care center, so we can determine what interventions may help," says Anna Page, RN, director of utilization management for Passport Health Plan, based in Louisville, KY.
The goal of the program is to analyze members' emergency department usage during the normal business hours of primary care offices and determine the reason members are seeking care for non-emergent conditions.
"We can assume a lot of things, but we don't know until we talk to patients the reason they are using the emergency department when the primary care provider offices are open," says Maureen Ritchie, RN, manager of clinical programs. "Right now, we're gathering information to decide what steps to take next. Meanwhile, we do provide education to the members on the appropriate use of the emergency department." Passport Health Plan identifies members through emergency department facility reports and through claims review. The calls are made by the health plan's ER coordinator, a non-clinician who has been with the health plan for 10 years. His duties include making outreach calls to members as well as the emergency department calls.
"We ask if they had treatment before going to the emergency department or if they contacted our 24-hour nurse line. Sometimes they don't know their primary care provider or the office is not convenient. In those cases, we help them identify their primary care provider or switch to one in a convenient location," Ritchie says. The ER coordinator educates patients on the appropriate use of the emergency department, plan benefits, and the use of immediate care centers. The coordinator also encourages patients to call their primary care providers or the health plan's 24-hour nurse line after hours.
In addition to the outreach calls, the plan sends direct mail to members to educate them about appropriate treatment options for specific non-emergent complaints. For instance, the materials about the common cold offer information on how to treat a cold at home and what symptoms indicate that they should call their provider. Members who frequently use the emergency department or those with asthma, diabetes, or high-risk pregnancy are referred to case management and disease management for follow up.
Passport also has case managers embedded in local primary care offices who meet with members face-to-face and educate them about appropriate levels of care if they have had a non-urgent emergency department visit.
In August, the health plan began a pilot project that locates a case manager in the emergency department of a small local hospital that treats a large number of health plan members. The Passport nurse in the emergency department conducts a brief interview with members to find out why they are using the emergency department and what barriers they have to receiving care in a more appropriate setting.
Among the questions she asks are: Do they know who their primary care provider is? Did they contact their primary care provider? How did they get to the emergency department?
The nurse educates patients about the health plan's 24-hour nurse line and other resources available to members such as case management and disease management services.
"Our goal is to analyze three months of data in order to determine and see if it's feasible to roll this out to other facilities where we have a lot of high emergency department rates," Page says.
When members of Passport Health Plan use the emergency department for non-urgent conditions, the health plan calls them to find out why they chose that level of care.Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.