- The healthcare industry is grappling with issues tied to avoidable emergency department (ED) visits, a costly trend that serves as an important indicator of lacking care management. In Milwaukee, a community organization is working to reduce ED visits through better community care coordination.
“We consider ED overutilization as two areas,” said Greg Stadter, the program director of the Milwaukee Health Care Partnership (MHCP), a program geared toward coordinating care across the region. “One would non-emergent care, so utilization coming from something that's not a true emergency.”
That avoidable ED utilization has considerable cost risks for healthcare organizations, data from AHRQ shows. Between 13 and 27 percent of ED visits could be referred to a primary care clinic, urgent care center, or retail clinic, thus saving the healthcare industry $4.4 billion annually.
“The other would be a condition that was an emergency by the time the patient got to the ED, but it was for a chronic condition that, if treated in the weeks before by a primary care physician, wouldn't have become an emergency,” Stadter added during an interview with PatientEngagementHIT.com.
In these cases, ED clinicians may see a need for better care management and an intervention from a primary care provider.
“When a patient establishes primary care and has ongoing management of their chronic conditions, there is a better outcome,” Stadter explained. “Patients don't get to the point where it is an emergency and need to go to the emergency room as often.”
For underserved, Medicaid populations, getting into a primary care clinic can be challenging, Stadter noted. These patients may not know where to access a primary care provider, face transportation barriers, struggle with cultural barriers, or face a number of other factors keeping them from accessing care.
Some community leaders have worked to fill in the gaps, creating different healthcare partnerships to help connect patients with primary care providers. But those efforts are often siloed and fragmented, sometimes introducing more problems than solutions, Stadter said.
In 2007, a group of other healthcare leaders in the area created the Milwaukee Health Care Partnership (MHCP) comprised of four Milwaukee health systems, five federally qualified health centers (FQHCs), and other local, community, and state health agencies.
“Our mission is to improve health care access and lower cost of care for our low-income and vulnerable population in the county,” Stadter said. “Back in 2007, there were growing health needs and significant disparities in our community, being a large urban area. We found that there was a lot of well-meaning work going on in silos that was really fragmented.”
The program leaders wanted to bring together all of the individuals and groups responsible for ED referrals and primary care to see how they could improve healthcare, specifically as it pertained to preventable ED utilization among the Medicaid and uninsured populations.
The group developed an emergency department care coordination program that uses the ED visit to link chronic care patients with primary care physicians. And in the years since the program’s inception, MHCP has connected over 50,000 chronically ill patients with a primary care provider, cutting avoidable ED utilization by 44 percent.
Leveraging the manpower of eight adult EDs across Milwaukee county and 25 health homes, MHCP ensures chronic care patients receive a primary care referral right at the point of care. ED workers first mitigate the health issue that caused the ED visit, and then refers that patient to a primary care provider.
That is easier said than done, Stadter acknowledged. For one, ED clinicians and care managers are not working with an abundance of time.
“ED care managers are really busy and calling clinics trying to work through the phone tree and schedule was a really time-consuming endeavor,” he explained.
MHCP adopted a tool, MyHealthDirect, aimed at streamlining the referral process. The technology allows care managers to pull up a “menu” for patients, complete with different primary care provider options, appointment availability, and geographic location.
This approach puts patients at the center of healthcare decision-making, Stadter noted, because it allows patients to select a primary care provider based on patient need and preference. Those choices are broken all the way down to a clinic’s cultural competence, he added. If a patient has certain cultural needs or experiences a language barrier, they are able to select a clinic that can fill those gaps.
The program is also staring down patient data exchange challenges. Working with disparate providers can make it hard for all clinicians to view and use patient records. But because of the referral tool’s cloud software, it can plug into numerous different EHRs, Stadter added.
And through WISHIN, Wisconsin’s health information exchange, as well as limited use of fax machines, the MHCP is able to fill in any patient data exchange gaps that may arise.
Beyond the logistical planning of the ED referral, care managers still face yet another important variable: patient activation in primary care.
“If the health need is addressed in the ED, there's less motivation to go to primary care, so show rate is our number one metric we are trying to continuously improve,” Stadter said. “The information that's given to the receiving clinic with the patient's contact information, that's a really good starting point there.”
“The receiving clinics all reach out to the patients beforehand,” he added. “They actually call in person and say, ‘welcome to our clinic, this is what to expect,’ and do a warm welcome to the patient.”
MHCP also works to identify external barriers that keep patients from visiting a primary care clinician. Transportation barriers, for example, may pose a threat to patient show rates, but rideshare and non-emergency medical transportation programs through Wisconsin Medicaid do help.
“When applicable, we take advantage of those programs,” Stadter said. “Sometimes, receiving clinics will even pay for bus vouchers out of their own pockets. There's some variability in exactly how aid looks but trying to address transportation barriers has been another really nice approach.”
Improving patient education about primary care while still in the ED has been another key strategy, Stadter explained.
“We have some materials on the importance of establishing relationships with the primary care physician,” he noted. “These provide coaching to the patient of why is it important to establish care with the primary care provider.”
MHCP’s referral tool also creates patient printouts complete with bus line information, parking directions, and ways to get in touch with the primary care provider. ED care managers are in charge of reviewing these materials with patients, adding a human touch that Stadter said is also important to supporting transitions of care.
Of course, none of these efforts would be possible if the various MHCP stakeholders did not cooperate. While different healthcare systems and health clinics have their own priorities and programs, Stadter said that focusing on what unites these players is essential.
“At the end of the day, there's a shared mission behind it and a common goal that we want to reduce unnecessary utilization in our community,” he said. “We want to decrease wait times to be seen in the ED, clear out that space, and reduce costs.”
The organization also holds quarterly meetings between program leaders during which ED representatives and community clinics hash out issues and program hiccups. These meetings are geared toward overcoming problems as well as relationship-building and breaking down siloes.
Stadter himself also rounds with the program’s eight EDs and 20 safety-net clinics to identify individual problem areas and learn about positive lessons learned. An online dashboard displaying key quality metrics helps individual organizations assess their own progress in reducing avoidable ED admissions.
Perhaps most importantly, patients have reported the positive impacts of this program, Stadter said. Between improved access to culturally competent clinics to helping to connect patients with care options patients did not know existed, this program has made its mark on the community.
At the end of the day, it’s the patient-centricity of allowing patients to choose from a menu of care options that has been most successful, Stadter concluded. By allowing patients to choose the care that will meet their personal, cultural, and scheduling needs, MHCP increases the likelihood that patients will follow through on accessing essential primary care.