Transcript Principal Investigator: Tina Bacorn, RN    Admission to ED numbers have been increasing.

Principal Investigator:
Tina Bacorn, RN
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Admission to ED numbers have been
increasing. Implementation of the Affordable
Care Act has increased the numbers
considerably.
Many of these admissions are not true
emergencies
Emergency department costs are the most
expensive way to receive primary medical care
Causes:
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Sluggish processes for patient throughput
Delayed care for patients with life threatening
medical conditions
Delayed relief of pain for patients who present
with acute injuries or illnesses
Contributes to the ever rising cost of healthcare
in America
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To determine the population using the emergency
department for non-emergent purposes
To determine the reason for their choice in using
the ED for non-emergent purposes
To correct any identified obstacles to alternative
primary care
To re-direct patients to more appropriate facilities,
the next time they have a similar complaint, by
giving them alternative resource information
To educate patients on their medical complaint
ULTIMATELY: Determine ways to reduce the nonemergent population of the ED
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Convenience sample of 100 patients was
obtained
Monday-Thursday
Within hours of 0900-1500
Genesis East Emergency DepartmentFast Track
During months of October and
November 2014
Inclusion criteria:
 Must be triaged at level 4 or 5, based on
standard ESI
 Practitioner to assess the patient and determine
the condition to be non-emergent, could be
treated else where, non-emergently, with equal
care
Exclusion criteria:
 Non-english speaking patients, pregnant
patients, and prisoners.
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Research candidates were presented with
informed consent explaining the study
Upon verbal consent, a series of questions were
asked of the patient including:
age, gender, primary medical complaint,
whether or not they had a PCP, insurance
status, and reason for choosing the ED for
their medical treatment
Based on their answers, patients were given
case specific resource handouts, treated by the
practitioner, and then discharged
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Of the 100 patients interviewed:
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52 were female, 48 were male
Median age was 24.5
All 100 patients were residents of Iowa
Answers were divided up into several categories:
Medical Insurance status
 PCP status
 Type of medical complaint
 Alternative resources given
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Medical Insurance Status
4%
10%
Medicaid/Medicare 68%
Self-Pay 18%
18%
Private Insurance through employer 10%
68 %
Commercial (insured through a specific health care
provider) 4%
Type of Non-Emergent Medical Complaint
3%
2%
Upper Respiratory Infection (cold/flu) 29%
4%
Acute Minor Musculoskeletal Injuries 25%
6%
29%
Chronic Pain Management (Narcotic Rx refills) 12%
6%
Skin Irritation (rash,insect bites) 7%
Laceration 6%
6%
Eye Irritation 6%
Migraine 6%
7%
Non-Pain Rx medication refill 4%
12%
Dental Pain 3%
25%
Non-Injury producing foreign body swallowed 2%
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100 % of the patients could have been seen at
an Urgent Care facility
86% of the patients could have been seen at
PCP within next 3-7 days, with equal care, and
with no additional harm
77% reported having a PCP. However, only 6%
reported having actually called their PCP to see
if they could be seen. The other 71% stated they
just assumed they would not be able to get in.
-The difference between sick slots and
routine check ups was explained.
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30% of the patients were given ORA
Orthopedics’ walk-in clinic
information: Open MondayThursday 1700-2000
92% of the patients given ORA
reference did not report severe pain
or distress and could have waited an
additional couple of hours to go here
instead
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23% of patients reported not having a PCP
Given Genesis “No Doc” phone number:
(563-421-DOCS)
 Given contact information and hours of operation on the
four community health care sites in the QCA
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18% of the patients reported not having medical
insurance
Given information on how to sign up for the affordable
care act, criteria requirements for Medicaid eligibility,
contact information on Genesis Financial Counselor
Representative, Rachel Pai for assistance in signing up
 Informed that Community Health Care also has
assistance in signing up for the affordable care act
insurance
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12% of the patients were seen for chronic pain
medication refills
All of these patients had already established
PCP care for their condition, but reported not
being able to get into see the PCP before they
either “ran out of meds” or the meds “weren’t
strong enough”
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Given Genesis policy on chronic pain management
in the emergency department
 Genesis’ policy is to not treat chronic pain with
narcotics due to the national epidemic of narcotic
substance abuse
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3% of the patients were seen for dental pain
Given 10 separate references for dental clinics,
including the Community Health Care clinic
that accepts walk-ins every morning, Mon-Fri,
starting at 0715am
Chronic pain policy also explained to those
patients who reported the dental pain lasting
longer than 6 months
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“Fast Track” is a common area of emergency
departments, set aside for minor injuries and illnesses
Fast Track is often overcrowded itself resulting in wait
times of over 2 hours (ideal door-door is 30 minutes)
Sometimes it can take 30 min-hour just to get these
patients triaged
“Convenience” was the number one reason reported for
why the patients chose the ED for their medical needs
May 2015: West campus ED saw approx. 3,200 patients
and East campus ED saw approx. 3,000 patients
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The most tested intervention to reduce the nonemergent use of ED’s was case management
Included a multi-disciplinary team of nurses, social
workers, and physicians
Locus of intervention not limited to the hospital
and often extended into the community
Strong evidence supporting a full time case
manager for “Fast Track”. Case management was
essentially what this research project turned into.
“In 2 before-and-after studies, the reduction in
hospital costs was larger than the cost of the case
management team.” (Althaus et al., 2011, p. 47)
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High Risk Population
68% had government funded insurance
18% were self-pay
4% had commercial insurance
Medical Insurance Status
4%
Medicaid/Medicare 68%
10%
Self-Pay 18%
18%
68 %
Private Insurance through
employer 10%
Commercial (insured through
a specific health care provider)
4%
Services and Supplies
Eligible Populations by Family Income
<100% FPL
101-150% FPL
>150% FPL
Institutional Care (inpatient hospital care, rehab
50% of cost for 1st day
50% of cost for 1st day
50% of cost for 1st
care, etc.)
of care
of care or 10% of cost
day of care or 20% of
cost
Non-Institutional Care (physician visits, physical
10% of costs
20% of costs
therapy, etc.)
$3.90
Non-emergency use of the ER
$3.90
$7.80
No limit
Preferred drugs
$3.90
$3.90
$3.90
Non-preferred drugs
$3.90
$3.90
20% of cost
Drugs
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Government insurance pays out based on a set fee schedule.
“The Iowa Medicaid Enterprise (IME) fee schedule is a list of the
payment amounts, by provider type, associated with the health
care procedures and services covered by the IME. Providers are
contractually obligated to submit their usual and customary
charges but accept the IME fee schedule reimbursement as
payment in full.” (Iowa Department of Human Services, 2014)
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Alternative interventions are now being
implemented in ED’s across America due to the
financial loss associated with these unpaid bills:
ADVANCED TRIAGE
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Nurse and practitioner in the triage room
Practitioner determines whether or not the
patient has a life threatening condition or if the
potential is there for a life threatening
condition to develop
Patients deemed non-emergent are then given
resource hand-outs for appropriate alternative
facilities, and then discharged w/o treatment.
Estimated door-door time on these patients is
less than 10 minutes.
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There are three criteria that should be met in order for this process to
occur:
1)“The hospital has determined, after an appropriate medical screening, that the individual
does not need emergency medical services.”
2)“An alternative non-emergency services provider is actually available and accessible in a
timely manner to provide the services needed by the individual.”
3)“The hospital has provided the individual with…the name and location of an alternative
non-emergency services provider (as described above); and a referral to coordinate scheduling of
the individual's treatment by this provider.” (Medicaid.Gov Keeping America Healthy, n.d.)
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Additional research for
Exact amounts of money lost due to unpaid bills of
non-emergent population
 Fast track case management trial, with follow up
phone calls, to identify and address any hurdles the
referred patients may have encountered
 Percentage differences of non-emergent to emergent
patient populations
 The policy/procedure and community reactions to
those hospitals doing Advanced Triage
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References
Althaus, F., Paroz, S., Hugli, O., Ghali, W. A., Daeppenn, J., Peytremann-Bridevaux, I., & Bodenmann, P. (2011, July).
Effectiveness of Interventions Targeting Frequent Users of Emergency Departments: A Systematic Review. Annals of
Emergency Medicine, 58(1), 41-52. http://dx.doi.org/10.1016/j.annemergmed.2011.03.007
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Genesis Financial and Billing Services. (2014). http://www.genesishealth.com/patients-visitors/billing/assistance/
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Huang, Q., Thind, A., Dreyer, J. F., & Zaric, G. S. (2010, July 9). The impact of delays to admission from the
emergency department on inpatient outcomes. BMC Emergency Medicine, 10(), 16-21. http://dx.doi.org/10.1186/1471227X-10-16
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Iowa Department of Human Services. (2014). http://dhs.iowa.gov/ime/providers/csrp
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Kang, H., Black-Nembhard, H., Rafferty, C., & DeFlitch, C. (2014, October). Patient Flow in the Emergency
Department: A classification and Analysis of Admission Process Policies. Annals of Emergency Medicine, 64(4), 335342. http://dx.doi.org/10.1016/j.annemergmed.2014.04.011
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Medicaid.Gov Keeping America Healthy. (n.d.). http://www.medicaid.gov/Medicaid-CHIP-Program-Information/ByTopics/Cost-Sharing/Cost-Sharing-Out-of-Pocket-Costs.html
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