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Grant helps ED refer patients to health center
Stabilization follow-up appointments arranged
After the first year of a two-year pilot program, the ED and the community health center participants agree that it has been successful in helping Medicaid and uninsured patients find the primary care they need. In addition, it has relieved some of the burden on the ED staff; in the past, length of stay (LOS) for those patients who went to the fast track has been as high as 90 minutes, while LOS for these patients has been under 70 minutes.
The ED at Monmouth (NJ) Medical Center, which sees about 54,000 patients a year, reports that 20% of its patients are Medicaid/Medicaid managed care, 20% are Medicare/Medicare managed care, and 20% are self-pay.
With the help of a $2 million grant from the Centers for Medicare & Medicaid Services, the ED was able to staff up to the point where it can refer all such patients to the Monmouth Family Health Center for follow-up visits after they have been screened and stabilized. The ED always had referred patients to the health center, says Catherine Hanlon, MD, FACEP, chair of emergency medicine, but in the past they would simply give the patients a phone number and leave it up to them to call.
The grant made possible the hiring of a full-time staff of nurse practitioners who handle the intake, evaluation, and treatment, and also coordinate follow-up and education for patients who use the ED for primary care visits. The ED added 12 hours a day of advanced practice nurses during the busiest hours: 9 a.m. to 9 p.m. The grant provided for three FTEs, but Hanlon decided to fill that with four part-time individuals.
"A shared computer database gives us instant access to the health center scheduling so they can arrange the follow-up visit," notes Hanlon. "Then case workers provide additional follow-up, such as arranging for transportation."
Bill Vasquez, FACHE, the project director, says, "The grant also provided not only for project direction, but increased clinical capacity at the health center. It also provided for additional physician hours, family medicine, nursing, and case management."
The triage process at the ED works like this: Any ambulatory patient has to register. Those with chief complaints that would be considered primary care complaints become candidates for referral. "We worked on a triage list of the most common office diagnoses, such as sore throat, removing stitches, wound checks, and earaches," Hanlon explains. "Whether the patient has insurance or not, they are still seen and taken care of by midlevel staff."
Once the patient is identified as having a primary care complaint, those who are uninsured or on Medicaid are seen right in triage by the nurse practitioner, rather than being sent to fast track, she says. "The complaints are addressed, treatment is initiated, and then arrangements can be made for the health center appointment right there," says Hanlon.
The program has streamlined the treatment of ED patients with less urgent problems "and lets the ED staff and doctors primarily focus more on the more seriously ill and injured patients," she says. In the past, length of stay for those patients who went to the fast track has been as high as 90 minutes, Hanlon says. "The last time we looked, the length of stay for these patients has been under 70 minutes," she reports.
The computer connection has been invaluable, Vasquez says. "It gives you the ability to make a real-time appointment at the moment the person is still in front of you," he says. "If you want an appointment that is available at, say, 3:15 on a Wednesday, that information is electronically communicated to the health center and then blocked out." The next morning, the case manager will pick up the appointments and contact the patients to ensure they can get there, he says. The software also has the benefit of including all of the patient's clinical information, he says.
Hanlon says, "That makes for very good continuity of care."
For more information on referring patients to a local community health center, contact:
Where do you find $2 million?
Any ED would be thrilled to have $1 million to improve its staffing and processes. How did the ED at Monmouth (NJ) Medical Center get "lucky" enough to split a $2 million grant from the Centers for Medicare & Medicaid Services (CMS) with the Monmouth Family Health Center to create a referral program for Medicaid and uninsured patients with primary care complaints?
Actually, luck had little to do with it, explains Catherine Hanlon, MD, FACEP, chair of emergency medicine. "I was approached to provide demographic data that would show how many Medicaid or uninsured patients we were seeing per month in the ED for primary care needs, how many use the health center, and how many would have access to it," Hanlon says. "We submitted the data from our side, and the health center submitted their availability for appointments."
Bill Vasquez, FACHE, the project director, says, "The source of funding originated with CMS, which created a pool of dollars they made available to 15 or 18 different states. New Jersey Medicaid, along with the Health Research and Education Trust of New Jersey, developed a proposal to create two demonstration projects in counties that had a high percentage of Medicaid visits per 1,000." The Monmouth facilities, and two in Newark, won the competitive bid process, he notes.
The million-dollar question
The pilot program is halfway through its two-year term. What happens when the money runs out? Hanlon says, "That seems to be the million-dollar question. From a productivity standpoint, if you only see 12-15 patients in a day, it's not really cost-effective. We may look at continuing the concept of seeing these patients, but maybe they'll be identified through extra general staffing."
Vasquez says, "Do the savings to the Medicaid program in fact result in an ability to continue to support a model like this? That will be one of challenges when the grant is done."
Referral program ensures follow-up
Good Shepherd Medical Center in Longview, TX, didn't have the benefit of a multimillion-dollar grant to help ensure ongoing care for its patients who lacked a medical "home," but it nonetheless has implemented a program that seems to be working.
"Our ED sees just fewer than 90,000 visits per year, and approximately 30,000 are by patients who do not have a primary care physician," says Ron Short, PT, MBA, FACHE, vice president of operations. "We wanted to find some way to be able to not only, hopefully, reduce ED volume of patients coming in for episodic care of routine complaints, but to also be able to establish these patients with a primary care physician to ensure continuity of care for conditions like diabetes and hypertension."
Joey Sutton, coordinator of CareDirect, the program that coordinates the referral system, has an office located around the corner from the ED. Sutton says, "It's a service for the patients and the community. We do not just treat people and release them, but we take intentional steps to help them get follow-up."
The idea was pitched by the hospital CEO, Short says. Then he, Sutton, and Crystal Thornton, BSN, the ED clinical director, designed the program. It works like this: When patients are identified as not having a primary care physician — usually in the pre-triage check-in or by the triage nurse — it is noted in their charts. "I also have access to MEDHOST [software, www.medhost.com/Home.aspx], which manages the patient records, so I keep lists of which patients I see that do not have a primary care physician listed, and I make it a point to visit those patients," says Sutton. "Also, the ED doctor or staff member can page me directly through MedHost and order a consult."
Sutton tries to see all patients before they are discharged to verify that they don't have a primary care physician and, if not, find out whether they are open to referral assistance.
Before the program was launched in late October, the triage nurses were educated about the program.
Thornton says, "They are usually the people who will let Joey know when to see the patient, although he knows the flow of ED and the best time to go in and talk around nurse and physician care." The physicians also were briefed during a staff meeting and via e-mail, she says.
Sutton talks with the patients about finances and insurance. About one-third of the patients who do not have primary care physicians have insurance. He will make arrangements if they are needed. "Occasionally, the ED doctor feels they need follow-up with a specialist like an orthopedist or a cardiologist. I can help make those appointments for patients as well," Sutton says. "Some patients indicate preferences [for specific kind of doctor], and I try to honor that request as best I can."
Sutton makes the appointments and then goes back in with the patients. "They get a folder that contains all the new patient paperwork for the office as well as the appointment information, so when they leave they have all they need to know," he explains. The day before the appointment, the patients receive a reminder call from the hospital's "Healthy Hotline," which confirms that they can keep the appointment or reschedules for them. "After the appointment, they get a follow-up call to see if everything went well," Sutton says. "I also contact the clinics to make sure the patient showed up."
Thornton has seen a decrease in minor emergency visits (she has not yet pulled length-of-stay data), but she is not yet ready to give all the credit to the new program. "The last couple of months have been strange for ED visits," she says. "Nationally, most EDs saw a drastic drop in volumes in November and December." Short confirms that observation. "Most places were down 12%-15%," he says. "We were down about 10%."
"Although it is too early to attribute a decline in ED volumes to the new program, Good Shepherd leaders will monitor volumes over the next quarter to identify causes and make necessary improvements to the CareDirect program," adds Sutton.
For more information on finding patients medical "homes," contact: