Strategic PlanPrepared By: Pramila Viswanathan, MD., MBA

GOAL Decrease the use of emergency rooms for non-

emergency treatment Decrease preventable ER visits, those with diagnosis

meeting the Appendix F criteria

OBJECTIVES

To help health plan members get better quality of care

Reduce the cost of healthcare provided

Strategies in Support of the

Goals and Objectives

Analytics Education Marketing Physician /Staff outreach Health Plan

Analytics

Analytics:

Identify members with avoidable ER visits (frequent flyers) from the claims data of the last 2 years, classify as low, medium and high utilizers

Identify population:1. Chronic disease2. Narcotic scripts3. Demographics

Identify top 10 diagnosis (appendix F) Identifying providers of care with high ER rate

Survey: Frequent flyer members-

Reason for their ER preference over office visits/urgent care centers

Barriers for their primary care use – communication, lack of knowledge about the alternatives to care, after office hours….

What one thing had they had knowledge of, would have helped them decide to see their primary care provider/urgent care rather than ER 

Providers of care- What was done different among those who had low ER

utilization What characteristics do they attribute their high ER

utilization rate

Education

Patient/Members

Help them understand when to use ER, as ER lacks important information from their medical history

Educate about primary care and preventative care Web based resources Access to Nurse triage line 24/7 Publication “Health wise” handbook to all members who used

ER for ambulatory sensitive condition, with access to online version of the handbook, which includes an interactive symptom checker

Triage Nurses/Call center

About outreach programs in the community, availability of care coordinators, CM… to enable them to connect directly to their care coordinators/CM 24/7

About after office hours urgent care center, alternative care centers in the community, locations and contact information…

RN triage and actually prescribing medications for certain complaints eg: UTI, following the nursing guidelines, provided the IL state nursing practice act allows for the same

ER

Maintaining real time ER registry and educating the staff on notifying the PCP’s of their members ER visit and outcome

 

Marketing Urgent care/walk-in clinics

Brochures

To all their frequent flyers, send brochures with information on when to use ER with examples of situations where urgent care would be safe alternative to emergency rooms

Brochures and posters distributed to physicians office with how to access help for urgent care needs fast with information about safe and effective alternatives to emergency room , with hours of operation, locations, phone numbers -

Nurse Triage 24/7

Information of the after office hour’s clinic, alternative care sites/urgent care centers, locations, phone numbers…

At ER Distribute pamphlets with contact number - triage

line, location of alternative care centers, after hours clinic

Outreach to frequent flyers to reconnect with their primary care provider

Schedule follow up appointment on behalf of patient after ER visit

Phone members after ER visits CM/RN to call members who used ER – Find out

if their needs were met and provide information of the alternative care locations, contact information of RN triage line….for future use nurse triage line urgent care centers care coordinators case managers

Physician/Members outreach

Multidisciplinary care team including medical director, nurse case manager, disease management care specialist, social worker meet monthly to review records of members with preventable ER visits –

Whether outreach doneHow best to help prevent future ER useDetermine the type of service that would help

the patient

Outreach to those members identified to benefit from care coordination, case management, to enroll in CM/DM/medical home…

Provide quarterly reports for physicians on their patients use of ER and their ER health outcomes

Outreach team to call members after ER visits, f/u if their needs were met and schedule visit with primary care provider

Health Plan

Health Plan: Expand urgent care network Provide patients with resource lists (brochures) for after hours

care, services offered by urgent care, list of situations what constitutes an actual emergency… at physicians offices…

Local Nurse lines/ RN Triage line – guide patients to safe convenient urgent care center in the community along with information on resources to help them with other issues such as transportation,…

Call members who used ER and inform about urgent care, link them with primary care provider, CM…

Send publications “Health wise” handbook available in English and Spanish, to all members who visited ER