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ED connects 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 increase clearly could complicate efforts to rein in costs, as ED visits are 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 of 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."
This 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. Furthermore, 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," Farrell 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, Farrell emphasizes. "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."
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. Still, the physicians had several 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 significant 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.
Track and report benchmarking data
When the program first launched, the physicians were comfortable with navigating only 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-5 population, and now any child over the age of 3 months can be navigated," explains Farrell, noting that the physicians themselves notified administrators when they were ready to expand the program.
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 upward 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. My guess is the next time we have this discussion, their numbers will be up."
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