Transcript R5 Initiative — Improving Access to the Right Care in the

R5 Initiative
— Improving Access to the Right Care in the Right Place at the Right Time
for the Right Reason at the Right Cost
2011 Study of Emergency Services
Utilization in the Capital Region of NY
Kevin Jobin-Davis, PhD
HCDI Members
County Health Departments
Albany County Department of Health
Rensselaer County Department of Health
Schenectady County Public Health Services
Hospitals
Health Plans
Capital District Physicians’ Health Plan
Fidelis Care New York
Senior Whole Health
Federally Qualified Health Centers
Ellis Hospital
Hometown Health Services
Albany Medical Center
Whitney M. Young, Jr. Health Services
Seton Health/St. Mary’s Hospital
St. Peter’s Health Care Services
Northeast Health/Samaritan Hospital/Albany Memorial Hospital
Community Partners
Catholic Charities of the Catholic Diocese of Albany
Healthy Capital District Initiative | www.hcdiny.org
HCDI – Improving Access to
Health Services
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Public Health Insurance
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Seal A Smile School-based Dental Services
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Free application assistance for Medicaid, CHP, FHP –
4,200 people served annually
Community Health Advocates - information and assistance
accessing health insurance and health services
Preventative oral health services – 3,250 served annually
Poverello Center
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Primary Care for Uninsured Adults – 350 served annually
Healthy Capital District Initiative | www.hcdiny.org
Public Health Planning
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Analyze available State & Local Health Data
Collect and Analyze local data
Support County and Hospital health
planning requirements – CHA and CSP
Develop local and regional initiatives
to address targeted health needs
Healthy Capital District Initiative | www.hcdiny.org
Target Population: Sub-optimal ER Users
The R5 Initiative
Improving Access to the Right Care in the Right Place
at the Right Time for the Right reason at the Right Cost
Health System
Forces
Primary care
availability
Referral policies
Support services
Intake/discharge
policies
Inter-organization
communication
Individual
Forces
Suboptimal ED Use
 Non-emergent
 Frequent flyers
 Preventable and
chronic illness
Pain
Knowledge of
health resources
Work conflicts
Transportation
Social support
Healthy Capital District Initiative | www.hcdiny.org
R5 Goals
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Identify causes of sub-optimal ED use
Identify promising practices and facilitate wider
adoption in the Capital Region
Improve patient & provider engagement with primary,
preventive, and managed care through collaborative
interventions, resulting in better health outcomes
Collaboratively develop protocols to improve patient
flow through the health system
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Healthy Capital District Initiative | www.hcdiny.org
2008 Capital District
Emergency Department Visits
Top 10 Primary Care-Related Diagnoses
ICD9 Diagnosis
Total
Acute URI NOS (#1 PCR Diagnosis for All & Children)
Urinary Tract INF NOS (#1 PCR Diagnosis for Women & Seniors)
Acute Bronchitis
Abdominal Pain-Site NOS
Dental Disorder NOS (#1 Non-Emergent Diagnosis)
Asthma NOS W Exacer
Otitis Media NOS
NonINF Gastroent NEC&NOS
Viral Infection NOS
Acute Pharyngitis
Grand Total
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4,148
3,205
3,040
3,035
2,983
2,956
2,835
2,719
2,691
2,686
30,298
Healthy Capital District Initiative | www.hcdiny.org
Top 10 Non-Emergent Diagnoses
Top 10 Non-Emergent Diagnoses
ICD9 Diagnosis
Dental Disorder NOS
Headache
Lumbago
Oth CCE Comp Preg-AP
Acute Pharyngitis
Urinary Tract INF NOS
Pain in Limb
Viral Infection NOS
Backache NOS
Migraine NOS W/O Sm
Grand Total
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Total
2,677
2,172
2,146
1,810
1,767
1,479
1,421
1,383
1,344
1,293
17,493
Healthy Capital District Initiative | www.hcdiny.org
Primary Care Related Emergency Department Visits
70%
60%
50%
% Sub-Population Visits
Primary Care-Related
40%
% All Primary CareRelated ED Visits
30%
20%
10%
0%
Private Insurance
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Medicaid
Self Pay
Medicare
Black
Other
White
Healthy Capital District Initiative | www.hcdiny.org
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Healthy Capital District Initiative | www.hcdiny.org
Consumer Survey
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HCDI developed a voluntary, anonymous consumer
survey to be distributed in local EDs to determine the
key factors that affect a person's decision to choose
an ED for health care
575 surveys were collected from Albany Memorial,
Ellis, Samaritan, Albany Medical Center and St.
Peter’s
Surveys contain a combination of open-ended and
multiple choice questions on Likert scale
Healthy Capital District Initiative | www.hcdiny.org
Results Reporting
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Open Ended Questions
Top Reason and Top 3
Health Condition vs. Provider Characteristics
Why this Particular Emergency Department
Closed Ended Questions
5 point Likert Scale
Strongly Disagree to Strongly Agree
Healthy Capital District Initiative | www.hcdiny.org
Consumer Themes for
Selecting Emergency Care
Table I: Top Reason Patients Chose ED for Care
Theme
% Respondents
Responses
Health Condition Characteristics
50%
287
Convenience
17%
97
Provider Service Quality
15%
84
9%
50
10%
57
Doctor Referral
Other
Table II: Top 3 Reasons Patient Chose ED for Care
Theme
% Respondents
Responses
100%
575
Convenience
53%
304
Provider Service Quality
45%
260
Doctor Referral
14%
81
Other
29%
165
Health Condition Characteristics
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Healthy Capital District Initiative | www.hcdiny.org
More Specific Factors
for Selecting Emergency Care
Table III: Health Condition Factors in Top 3 ED Use Reasons
Factor
% Respondents
Responses
Symptoms
53%
305
Pain
34%
197
Severity / Urgency
11%
62
3%
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Unintentional Injuries
Provider Related Factors in Top 3 ED Use Reasons
Factor
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% Respondents
Responses
Quality of Care
40%
231
Proximity
21%
122
Quickness
17%
100
Hours of Operation
14%
82
Medical Referral
12%
67
Healthy Capital District Initiative | www.hcdiny.org
Factors in Selection of Particular
Hospital’s Emergency Services
Table IV: Primary Reasons Patients Selected Particular ED by Theme
Theme
Responses
Convenience
52%
277
Provider Service Quality
39%
206
Prior Visits
26%
139
Doctor Referral
5%
29
Stated No
4%
20
Health Condition Characteristics
4%
19
14%
77
Other
17
% Respondents
Healthy Capital District Initiative | www.hcdiny.org
Consumer Defined Rationale
for Choosing Emergency Services
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Overall, symptoms and convenience are the driving
factors for people to seek care
Pain and the quality of care are important secondary
considerations
Selection of particular emergency service providers,
is similarly influenced by convenience, then service
quality factors, with prior visit experience also a
consideration
Healthy Capital District Initiative | www.hcdiny.org
Most Commonly Shared Reasons
for Seeking Emergency Services
Symptoms as Motivation for ED Visit
Needed care immediately
Needed care that day
Needed care within 2 days
Pain was primary motivation for visit
Service Qualities as Motivation for ED Visit
Specialists, lab tests, and x-rays all at one place
Do not need an appointment at ED – timely service
ED accepts all patients regardless of insurance coverage
Cost of ED co-pay was not a concern
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Strongly Agree or Agree
89%
84%
53%
76%
Strongly Agree or Agree
80%
73%
68%
37%
Healthy Capital District Initiative | www.hcdiny.org
Phone Triage and Access Issues
Consulted with Medical Personnel Prior to ED Visit
Consulted primary care doctor before going to ED
Consulted a nurse help-line before going to the ED
Staff at residential facility referred to the ED
Ambulance transported to ED
Access to Other Health Providers
Hospital is easier to get to than doctor's office
No transportation to doctor's office
No transportation to urgent care center
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Strongly Agree or Agree
25%
16%
13%
11%
Strongly Agree or Agree
57%
14%
14%
Healthy Capital District Initiative | www.hcdiny.org
Consideration of Urgent Care,
Primary Care, and Emergent Care
Considered Urgent Care Centers Prior to ED Visit
Considered urgent care centers
Unsure of urgent care centers' hours
Urgent care centers closed
Prefer ED as Primary Provider
Usually use ED for health care
ED better place to get health care than a primary care doctor
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Strongly Agree or Agree
28%
21%
20%
Strongly Agree or Agree
20%
20%
Healthy Capital District Initiative | www.hcdiny.org
The Convenience of
Accessing Emergency Care
Service Qualities as Motivation for ED Visit
Specialists, lab tests, and x-rays all at one place
Do not need an appointment at ED – timely service
ED accepts all patients regardless of insurance coverage
Hospital is easier to get to than doctor's office
Considered urgent care centers
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Strongly Agree
or Agree
80%
73%
68%
57%
28%
Healthy Capital District Initiative | www.hcdiny.org
The Inconvenience of
Accessing Primary Care
Strongly Agree
or Agree
Availability of Primary Care Provider
Do not have a primary care provider
Without prior well doctor visit, doctor wouldn't allow sick visit
No doctor appointment available within 2 days
Doctor's office was closed
Unsure of doctor's office extended hours
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33%
14%
35%
34%
24%
Healthy Capital District Initiative | www.hcdiny.org
Summary of Patient Reasons for
Selecting Emergency Health Services
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The sense of urgency (84%) and pain (76%) associated with
the trauma is the primary motivation for seeking emergency
services
The convenience of comprehensive, timely services regardless
of insurance are the major draws for patients
Patients don’t distinguish clearly emergent from primary care
treatable conditions (42% of ED visits)
The vast majority (80%) do not consider the ED a better source
of care than primary care
Not establishing a primary care provider was a factor for 1 in 3
respondents
Healthy Capital District Initiative | www.hcdiny.org
Methods of Gap Analysis
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Discussion/Meetings
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35 different providers (e.g., primary care physicians,
emergency department (ED) nurses, patient navigators,
case managers, urgent care clinic nurses, medical directors,
discharge planners, long-term care providers, and others
Surveys
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13 primary care doctors
3 hospitals
4 nursing facilities
3 urgent care centers
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Healthy Capital District Initiative | www.hcdiny.org
Major Gaps
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Care management
Patient handoff
Capacity
Protection from liability
Alternatives to the ED
Healthy Capital District Initiative | www.hcdiny.org
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Primary Care Providers (PCP)
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Capacity and support for timely preventive care is
lacking
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Payment systems do not support robust primary care
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Some PCPs don’t accept MA; wait before seeing PCP
PCP shortages are acute for certain health conditions
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No reimbursement for extra time managing care
There are extra challenges for the publicly insured
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Same day appointments at primary care offices limited
Dental, mental health, and substance abuse were cited often
Healthy Capital District Initiative | www.hcdiny.org
Hospitals
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EDs are not geared to manage care
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There are barriers to effective follow-up
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Focus is emergent care, not chronic care
Little time to educate patient; limited record
exchange
Healthy Capital District Initiative | www.hcdiny.org
Hospital / PCP
Care Coordination Findings
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EDs communicate with affiliated physicians
EDs communicate with PCP re: admissions
FQHCs typically must actively seek info
Other instances, follow-up left to patient
Healthy Capital District Initiative | www.hcdiny.org
Long Term Care / EMS
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Senior housing can’t manage residents’ health or
provide services
Many home and community-based providers fear
liability if they don’t send patients to the ED
If called, EMS must take patients to the ED
Healthy Capital District Initiative | www.hcdiny.org
Urgent Care Centers (UCCs) and
Federally Qualified Health Centers (FQHCs)
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There is not widespread awareness about
UCCs or FQHCs as an alternative to the ED
UCCs not located in urban areas
Certain diagnostics only available at ED
Service hours are limited
Healthy Capital District Initiative | www.hcdiny.org
What to Do?
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Improve Access to Primary and Preventive
Care
Help Consumers Distinguish Primary Care
Treatable Conditions from Emergent
Bolster Communication between Emergency
Departments and PCPs
Healthy Capital District Initiative | www.hcdiny.org
ACCESS TO PRIMARY AND
PREVENTIVE CARE
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Facilitated Enrollment education on
importance of primary care/well visit and
assistance with securing PCP
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Development of evening primary care
services in urban centers
CONSUMER SELECTION OF HEALTH
SERVICES
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Develop messaging and materials on
benefits of primary care to support referrals
of ED patients without a PCP
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Targeted outreach in areas with high self-pay
population
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Develop marketing campaign on the benefits
of Primary Care
COMMUNICATION BETWEEN EMERGENCY
DEPARTMENTS AND OTHER PROVIDERS
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Launch pilot exchange of ED visit information
with primary care group
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Enhance referral processes of ED patients
without a PCP to primary care
Contact
Healthy Capital District Initiative
315 Sheridan Ave.
Albany, NY 12206
www.hcdiny.org/r5.htm
Kevin Jobin-Davis
(518) 462-1459
[email protected]
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Healthy Capital District Initiative | www.hcdiny.org