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Medicaid Quality Incentive: Plan for Reducing Preventable Emergency

Room Visits

Department of Social and Health ServicesHealth & Recovery Services Administration

Thuy Hua-lyJeff Thompson

Vazaskia CaldwellBeverly Court

April 19, 2011

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• Engage hospitals in quality improvement– “Float all boats” rather than rewarding highest– Pairing monetary incentive with collaborative

learning and “safe table” forums– Systems approach (include community

partners)

• Focus on Medicaid managed care

population

Medicaid Quality Incentive Policy Intent

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Five Measures– Healthcare Worker Flu Immunization– Patient Discharge Information– Elective Delivery Prior to 39 Weeks– Reducing Preventable Emergency Room Visits– Patients Discharged on Multiple Antipsychotic

Medications with Appropriate Justification

Incentive Structure

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• Each measure scores 0, 3, 5 or 10 points• Hospital qualifies for 1% rate increase if

has average score of 5 or higher• Public acknowledgement of hospitals

with average of 10 points• No partial or pro-rated incentive

payments allowed by the enabling legislation.

Incentive Scoring

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• First year – a comprehensive hospital plan• Plan has 5 sections– Community Partnerships– Data Reporting– Strategic Plan for Prevention of Visit– Emergency Room Visit Follow-up– Continuing Education

• Points– 3 sections – 3 points– 4 sections – 5 points – 5 sections – 10 points

Reducing Preventable Emergency Dept Visits Measure

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Documentation that infrastructure is in place which includes relevant community partners

• Name and addresses of Emergency Departments, both on and off campus

• Names and positions of hospital staff and community partners in workgroup.

• Minutes of workgroup meetings with future meeting dates. Workgroup with relevant community partners must have met at least once prior to plan approval.

Section 1: Community Partnerships

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Evidence of collection and analysis of data upon which to create an informed plan.

• Data report which identifies preventable ER visits using standard methodology such as MediCal groupings, New York University groupings, or own version.

• Report should identify visits for Medicaid managed care clients by Healthy Options plan, at a minimum.

• Identification of the top five reasons for potentially avoidable ER visits.

Section 2: Data Reporting

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Creation of strategies to prevent visits• Develop at least two strategies with

community partners to help patients learn in advance of arriving in the ER how to access care in less expensive location. Must include full work plan description, who, what, where, when, how.

• Refrain from explicitly soliciting primary care visits to the hospital’s ER in marketing materials such as billboards, radio, scripts, etc.

Section 3: Strategic Plan for Prevention of Visits

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Create strategies addressing patients who have arrived in the Emergency Department

• Minimum 2 strategies with community partners addressing patients who have arrived in the Emergency Department but could be seen in less expensive location.

• Describe method of identifying patients and notifying managed care organizations or their designated primary care clinics of the client’s use of the ER in a timely way, either in-place or in process of implementation.

Section 4: ER Visit Follow-Up

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• Evidence of at least one hospital team member attending educational programs by the state, such as web conference for CEOs, ER Directors and key administrators or an in-person meeting on best practices.

Section 5: Participation in Continuing Education

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• Use Plan Template or Word document with similar format

• No more than 15 pages• Send via e-mail to

MedicaidQualityIncentive@dshs.wa.gov• Hospital plans will be posted for the

public via Medicaid’s news website at http://hrsa.dshs.wa.gov/News/index.htm

Submission Process

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Emergency Department Alternative Care Grant

• Washington State DSHS/MPA– Funded by CMS– 1 of 20 State Successful Bidders– 2 years of grant funding– $1,963,581 grant– To establish Alternative Non-Emergency

Service Providers or Networks of Such Providers through grants

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COLLABORATIVE PARTNERS

• Washington State Hospital Association (WSHA)

• Washington Association of Community and Migrant Health Centers (WACMHC)

• DSHS Research and Data Analysis Division

• Dr. Fred Connell, University of Washington

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4 PILOTS & PARTNERS• Community Health Association of

Spokane– Partner: Holy Family Hospital

• Lourdes Health Network – Partners: Miramar Clinic and TriCities

Community Clinic

• Health Point Community Health Clinic– Auburn Regional Medical Center

• Interfaith Community Health Clinic– Peace Health St. Josephs Hospital

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INTENT OF THE PILOT

• Develop and Test a variety of initiatives aimed at reducing inappropriate emergency department use among Medicaid enrollees (ME)

• Connect ME with medical homes and case management services

• Educate ME about the appropriate use of emergency departments and primary care

• Improve access to primary care

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PILOT STRATEGIES• 3 Required Strategies: – 24 hour access to professional services by ‐

providing a nurse triage line in project ‐communities,

– Improve the ability of community health clinics (CHCs) to be effective Medical Homes and alternate emergency care providers, and

– Create a case management system that is integrated with the nurse triage system to follow‐ ‐up on emergency department visits and connect patients with other needed services.

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EFFECTIVE PRACTICES Direct communication between partner sites Sharing of information to ensure high quality

medical care Well-defined and proactive referral process Pain management program DSHS Patient Review and Coordination Care coordination Patient Advocate Clinic/ER Liaison Community-wide education

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PILOT STATUS

• Pilot ended on April 14, 2011• DSHS Research and Data Analysis in

collaboration with UW will be producing a pilot evaluation in July 2011

• DSHS Medicaid Purchasing Administration in partnership with WACMHC will be producing a final report on pilots in July 2011

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Thuy Hua-ly e-mailMedicaidQualityIncentive@dshs.wa.gov

Washington State Hospital Association website

http://www.wsha.org/0382.cfm

More Information

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