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Peach State Health Plan

Emergency Room (ER) Management Program

Cara Johnson-Malbrough,

Director of Case and Disease Management Services

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“Peach State Health Plan will help our members grow healthy and

stay healthy by providing access to better healthcare”

Mission Statement

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Purpose

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The purpose of the ER Management Program is to

impact quality and outcome of care received by our members.

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Emergency Management Program

• The ER Management Program takes a dynamic and systematic approach to ensuring that the delivery of care is at the right time and in the right setting in effort to: – Decrease inappropriate ER usage– Promote the establishment of a medical home by our

members– Remove core barriers to why members use the ER– Provide member / provider education on plan benefits

Core Premises

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Emergency Management Program

• Identification Process– ER Frequent User Report

• Claims generated report

• Stratifies members by their condition and number of visits

– Hospital Notifications (Runner List)• 11 participating hospitals ERs

• Participating ERs notify the Plan withing 1 – 7 business days via fax or email

Program Components

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Hospital Notification List by Participating ProvidersHospitals Frequency of Submission

CHOA- Hughes Spalding [daily]

CHOA- Egleston [daily]

CHOA- Scottish Rite [daily]

Colquitt Regional [daily]

Columbus Regional [daily]

Henry Memorial [daily]

Memorial Hospital [daily]

West GA Health System [daily]

Archibold [Biweekly -Monthly ]

Houston [Biweekly -Monthly ]

Phoebe Putney [Biweekly -Monthly ]

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Emergency Management Program

• Outreach Services– NurseWise

– Cenpatico Behavioral Health (CBH)

– Nurtur (Asthma Disease Management)

– Case Management

Program Components

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Emergency Management Program

• NurseWise (24/7 Nurse Helpline) Outreach– Provide targeted education to members identified as using the

hospital ER inappropriately

– Outbound call (manual / Televox) within 24 – 48 hours to complete a screening assessment

– Audio postcard, and informational mailings (i.e. Conjunctivitis, Fever, Cold, Flu and Ear Infection)

– Identifies members with case or disease management needs and refers the case to the Plan for follow-up

Program Interventions

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Emergency Management Program

• Cenpatico Behavioral Health Outreach– Intensive Case Management (ICM) provided by licensed

social workers and allied health workers

– Completion of a comprehensive needs assessment

– Integrated plan of care for members with dual diagnosis

– Development of an individualized plan of care (POC)

– Facilitation of a relationship with a mental health provider

Program Interventions (cont’d)

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Emergency Management Program

• Nurtur (Asthma Disease Management) Outreach– Enrollment into the Disease Management Program

– Outbound call within 24 – 48 hours to complete an health assessment

– Health Coach collaborates with the members’ physician and/or specialist to develop an individual plan of care (POC)

– Home visit by certified respiratory therapist, if indicated

Program Interventions (cont’d)

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Emergency Management Program

• Case Management– ER F/U Assessments

• Assessment, performed post the ER intervention, used to determine if the member remained compliant with the ER discharge plan and followed-up with his/her PCP

– 90 - Day Case Management Program• Staffed by nurse case managers and allied health workers• Case management services provided to members identified as ER

frequent users and non-compliant with the ER discharge plan or the PCP plan of care

• Home visits, performed by CONNECTIONs staff, on members identified with multiple co-morbidities and unable to contact

Program Interventions (cont’d)

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Emergency Management Program

• Peach State recently completed the annual evaluation of the ER Management Program. The results yielded by some of the interventions were not as effective as anticipated.

– Members who received an intervention via audio postcard or informational mailings showed no significant decrease in ER utilization when compared to the peer group who received no intervention

– Predictive Dialing Outreach (Televox) yielded fewer telephonic connections when compared manual outreach

Program Evaluation

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Emergency Management Program

• NurseWise – New enrollees, between ages of 1 -10 and auto-assigned a PCP will

receive an outbound educational call within 90 days of enrollment into the Plan

– Develop and Implemented a new member mini - assessment

• Case Management – Outreach services associated with hospital notifications will be

managed at the Plan

– Educational interventions will target members auto assigned to a PCP

and had with 1-2 ER visits in past 6 months

2010 Program Enhancements

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PSHP ED Case Management Program

Opportunities for Program Expansion

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Emergency Management Program

• Identification– Forge a collaborative partnerships with area ERs to develop

multifaceted strategies for identifying and managing non – urgent ER frequent users

• ER Frequent Users Notification letters

• Reporting– Automatic referral or alert to the Plan within 24 – 48 hours or

next business day after the member is treated in the ER• Standardize reporting format

Opportunities

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PSHP ED Case Management Program

Questions?

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