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ED navigators connect patients to better venues of care
Long-term goal: Change consumer behavior
As reform helps more Americans gain access to health coverage, experts predict that the nation's EDs will be bulging at the seams. This could clearly complicate efforts to rein in costs, as ED visits are much more expensive than care delivered through physician office visits or urgent-care centers. However, to address this problem before it escalates, Albuquerque, NM-based Presbyterian Healthcare Services (PHS), an integrated system including eight hospitals, a health plan, and a growing medical group, is using what it calls ED navigators to re-direct patients with non-emergency issues to the most appropriate care setting for their needs.
In the model, providers determine whether a patient should be navigated to a less-acute setting during the medical screening exam. In these cases, an ED navigator will schedule the patient to be seen by another provider within 12 to 24 hours, explains Mark Stern, MD, medical director, medical management, and endcare coordination and an emergency medicine physician at PHS. "Most, if not all, emergency physicians will say there is a better venue of care for these types of patients in which they will receive better care at a cheaper cost," he says. "It usually doesn't work that way. That's one of the reasons why we began doing this in the emergency department."
Fully launched on July 26, 2010, the ED navigator program is now consistently navigating 12% to 14% of the ED volume to a more appropriate setting of care, but program developers believe there is much more opportunity yet to be realized. Further, they are particularly enthusiastic about the fact that only 3% of navigated patients have returned to the ED at a later date. This suggests navigated patients have been connected with a more appropriate care setting that they can turn to for their non-emergency needs, but it also makes financial sense for PHS, explains Lisa Farrell, CPA, chief financial officer of Presbyterian Health Plan. "If our return rate continues to be that low, then we expect to realize a cost reduction in the next three to six months," she says.
Get physicians on board
While health system administrators saw the ED as offering the greatest opportunity for improvement in re-directing patients to more appropriate settings of care, the task of implementing the ED navigator program was by no means simple, stresses Farrell. "We went to the media, we went to advocacy groups, and we went to regulators," she says. "We really wanted to get out very broadly what we were doing." (For more on this aspect, see ED navigator programs require partnerships, communications, below.)
However, the most critical piece involved explaining the program to ED physicians and getting them on board. "Where I started from is trying to shift the paradigm of the ED being the safety net for all patients in the community," says Stern. "What we wanted to do was leverage the integrated system by spreading out the safety net to all parts of our system, so ED physicians had to kind of change their mindset."
Stern says he had to get the physicians to trust that there is a better place for the non-emergency patients to go, and try to hook up with a primary care physician (PCP) with whom they can develop an ongoing relationship. Still, the physicians had a number of concerns, including how long it would take for the navigated patients to be seen and treated.
"That was a deal-breaker for this program. If we couldn't get the patients to another venue of care within 12 to 24 hours, then we [agreed] we would stop the program that day," says Stern, noting that this also helped to ease concerns some of the physicians had regarding liability. "Most of the physicians agreed that these [navigated] patients would, in fact, be safer than the patients who are seen in fast track and then sent home, because the navigated patients would be guaranteed of being seen by a second provider within 12 to 24 hours."
Another big issue for the physicians was cost. They were concerned about patients having to pay for a second visit if they were navigated to another provider, so Stern offered a guarantee that the patients would at least be seen once at another venue of care at no cost to them. "If the patient had insurance, the insurance would pick up the cost of care, and if they had no insurance, then PHS would deal with the charity piece," says Stern.
Track and report benchmarking data
When the program first launched, the physicians were only comfortable with navigating patients with just a handful of minor diagnoses, such as sore throat, ear infection, urinary tract infections, and minor abrasions, notes Farrell. In addition, they stipulated that any patient under the age of 5 or over the age of 65 would not be navigated. However, the physicians' comfort level with the approach grew rapidly.
"Within about a week of launching the program, they said they were comfortable with the over-age-65 population. Within a couple of weeks, they were comfortable with the under-age-five population, and now any child over the age of three months can be navigated," explains Farrell, noting that the physicians themselves notified administrators when they were ready to expand the program.
The program has also been tweaked in other ways upon the suggestions of physicians, says Stern. "Someone came in with a minor sprained ankle, and the physicians didn't want to send the patient out limping, so they were allowed to give crutches to that patient," he says. "Similarly, if a patient needs one dose of pain medication, we will do that so the patient can get to a more appropriate venue of care."
While physicians have clearly warmed to the program, there are, nonetheless, varying degrees of acceptance. "There are some physicians who really embraced this early and are navigating upwards of 25% of the patients they see on a daily basis, but there are also some physicians who are still at zero or very low levels," explains Farrell.
Stern emphasizes that physicians are not under pressure to navigate patients, but he provides constant feedback on their use of the navigator program. "On a weekly basis, they get to see how they personally compare to their peers in navigating patients, so they know if they are in the 20th percentile, zero percentile, or 28th percentile," he says.
Stern will meet physicians who are low users of the program to hear their concerns and reinforce the reasons behind the approach. "I don't force anybody to do anything, but I try to understand what their thoughts are and why they have been unwilling to navigate more patients," he says. "I have met with three physicians so far, and all of them were surprised that their numbers were so low," he says. "My guess is the next time we have this discussion, their numbers will be up."
Long-term goal: Change patient behavior
Also critical to the program are the ED navigators themselves, says Farrell. "They came out of our enterprise-wide contact center, so these are individuals who have a customer-service background, and they also have the ability to assign PCPs for our health plan members and to schedule appointments with providers in our primary care group," she says. "They have very broad access to the tools needed to get people into the right place, and they have the ability to talk to patients about the options that are available."
The way patients are navigated is crucial, because when you are sending patients elsewhere for care, there is certainly the potential for declines in customer satisfaction, but that hasn't been an issue for PHS thus far, stresses Farrell. "There are some hospitals that do navigation, but they just hand patients a list of 20 urgent-care centers and tell them that they can go to one of those. We don't do that," she says. "We actually take the time to sit down with the patients, talk to them about what we are doing, and get an appointment scheduled. We think that is one of the key reasons why we are not getting complaints."
In fact, the navigation process is an easy sell to patients who must pay for their care out-of-pocket, notes Stern. "When you tell them that [the care setting you are sending them to] is one-quarter or one-third of the cost of an ED visit, and that it is a much better venue for them for future [non-emergency] care needs, there are many patients who are very thankful for that because they didn't understand that they had other options," he says. "When we asked the patients we have navigated why they came to the ED, 93% indicated that they always come to the ED for care; it is how they have always cared for their family, and it is how their parents cared for their family, so there is literally decades of a culture of getting care in the community this way."
Currently, PHS has eight navigators who are covering two facilities, one of them remotely, and Farrell notes that ED navigators will begin serving a third hospital later this year. Coverage is around the clock, she says. However, the long-term goal of the program is not to keep navigating patients, but rather to change the way patients access their care. "In the short term, there is a lot of navigation going on, but over the long term, we expect that those individuals won't continue to come to the ED for non-emergent conditions," she says. "That is really the intent of the program: To change the behavior of individuals."
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ED navigator programs require partnerships, communications
As an integrated system, Albuquerque, NM-based Presbyterian Healthcare Services (PHS), is perhaps better-positioned than many health-care organizations to control all the levers that need to be pushed to get patients to the right venue of care, but Lisa Farrell, CPA, chief financial officer of Presbyterian Health Plan, emphasizes that the ED navigator model can work in other settings.
"There has to be a partnership with a payer that is willing to pay for the medical screening exam over the short term, and allow your cost structure to come down as people stop accessing the ED inappropriately," she says. "Right now, we have a lot of uninsured patients in New Mexico, and a very large percentage of the population is served by Medicaid, so 60% of the patients we are navigating are either uninsured or on Medicaid, where the reimbursement is very low, so for us the program makes a lot of sense."
In addition, Farrell points out that two Medicaid payers in New Mexico have begun to decline reimbursement for non-emergent care that is delivered in the ED, and health-care analysts expect that commercial payers will eventually follow suit.
For ease of scheduling, it is very helpful if the ED navigators have access to the schedules of community physicians, says Farrell. But it is also important to reach out to community physicians, let them know what you are doing, and establish a communications mechanism so that any issues or problems that crop up can be resolved.
"If someone is inappropriately directed in either direction, we will jump on that very quickly and try to address where the problem was," explains Mark Stern, MD, medical director, medical management, and endcare coordination at PHS, and an emergency medicine physician. "We will investigate, review the chart, and get feedback to whoever the physician is on either side. That has been very effective to getting the physicians' trust."
To implement an ED navigator program, some hospitals might need to take on additional staff, but Farrell suggests that another option that may be particularly attractive to smaller EDs is to have registration personnel play a greater role in the navigation process. "We think there is a variety of ways to do it," she says.