MAY 2016 ED SUCCESS: Coordinating Emergent and Nonemergent Care HEALTHLEADERS MEDIA INTELLIGENCE REPORT

Transcription

1 HEALTHLEADERS MEDIA INTELLIGENCE REPORT MAY 2016 ED SUCCESS: Coordinating Emergent and Nonemergent Care SUPPORTED BY: POWERED BY: W W W. H E A LT H L E A D E R S M E D I A. C O M / I N T E L L I G E N C E

2 PERSPECTIVE Improving ED Efficiency Requires a Team Effort Emergency departments have a unique responsibility to provide timely, high-quality assessment and care to any individual seeking medical assistance. But as any ED clinician, staff member, or hospital leader can tell you, there are a number of challenges that can interfere with the department s ability to fulfill that duty. Stephen Holtzclaw, MD President, Hospital Based Services TeamHealth According to the 212 healthcare leaders who completed the 2016 HealthLeaders Media Emergency Department Strategies Survey, the top challenges facing EDs today include difficulty accommodating an influx of mental health patients, long wait times, and bottlenecks in the ED-to-inpatient transfer process. To address those and other efficiency challenges, hospitals are deploying a number of strategies. For example, the majority of respondents said they have or will use fast-track or split-flow processes, streamlined registration for arriving patients, and direct or immediate ED bedding to help optimize their ED throughput. My hat is off to those hospitals taking action to improve ED efficiency. At TeamHealth, we know from our work with thousands of hospitals around the country how important it is to the financial and operational health of a hospital to have an efficient, high-performing emergency department. The best-performing EDs help hospitals capture additional revenue, reduce their overall costs, and improve the patient experience. We also know an effective strategy for one facility may not work for another. Each hospital s unique circumstances from its geography and local market conditions to the relationship between the emergency department and hospital medicine teams must be considered when determining how to address efficiency challenges. There is no one-size-fits-all approach. For example, some hospitals may find effective relief for long wait times by optimizing their staffing levels, and others may need a more aggressive patient-flow redesign. What we have found to be consistent across the most efficient and successful EDs is their ability to garner support and participation from an interdisciplinary team of providers and staff members. These hospitals secure buy-in from leaders, physicians, nurses, and staff members not only in the ED, but also in coordinating departments like hospital medicine to make sure ED efficiencies drive through the entire continuum of care without creating unforeseen challenges or congestion elsewhere. In addition to a team-based approach, successful EDs have a relentless commitment to tracking, monitoring, and improving their metrics. In fact, a thorough metrics analysis is usually the critical first step to determining the true, underlying efficiency challenges an ED is facing, as well as a necessary foundational step in building the right, tailored strategy to address those issues. With 70% of survey respondents forecasting an increase in ED patient volumes within the next three years, now is the time for all hospitals to conduct that self-analysis, build their internal teams, and determine the best strategy for improving ED efficiency. PAGE 2

3 TABLE OF CONTENTS PERSPECTIVE FOREWORD... 4 ANALYSIS FIGURE 1: Annual Visits to ED FIGURE 2: ED Challenges...12 FIGURE 3: Bottleneck Problems for ED Flow...13 FIGURE 4: Average Time Between Decision to Admit and Time Patient Leaves ED...14 FIGURE 5: Operations Techniques to Increase ED Throughput...15 FIGURE 6: Operations Techniques to Optimize ED Throughput Next Three Years...16 FIGURE 7: Status of Telemedicine Deployment in the ED FIGURE 8: Principal Telemedicine Applications in ED...18 FIGURE 9: Expected ED Area Increases Next Three Years...19 FIGURE 10: Tactics to Minimize Avoidable ED Visits FIGURE 11: Status of Alternative Care Settings FIGURE 12: Care Setting With Most Potential to Improve Industry s Ability to Deliver Value-Based Care...22 FIGURE 13: Motivations for Pursuing Urgent Care Clinic...23 FIGURE 14: Provider/Service Effectiveness in Helping Patients Make Appropriate Use of ED...24 METHODOLOGY RESPONDENT PROFILE PAGE 3

4 FOREWORD Increasing ED Efficiency Becomes Key Focus Hospital administrators long have said that emergency departments are the Statue of Liberty of healthcare: accepting the tired, the poor, and those who don t necessarily need emergency care but have nowhere else to go. Trisha Cassidy Chief Strategy Officer AMITA Health Arlington Heights, Illinois But in the era of healthcare reform, a new ED view is emerging. As readmission rates become a critical measure for hospitals, as population health teams seek ways to connect with patients before acute events, and as providers become more responsible for the total cost of patient care, hospitals are reassessing and reshaping the ED s role in the care continuum. While triage and patient care remain top priorities, running an efficient ED has become a key focus. The 2016 HealthLeaders Media Emergency Department Strategies Survey results highlight several barriers to efficiency, including in-ed patient flow, availability of inpatient beds, and patient flow outside the ED. Yet the single greatest ED challenge, noted by 35% of respondents as the top challenge and among the top three by 70%, is accommodating mental health patients. They tend to experience long wait times in EDs, as evidenced by the 62% of respondents who cite behavioral health patients occupying ED beds as the second-greatest reason for ED bottlenecks. Why is behavioral health such a critical ED issue? There are several contributing factors, including reductions in state-funded behavioral health services, a shortage of behavioral health physicians, and patient-safety concerns (especially when self-harm is a possibility), which can cause EDs to keep a patient under observation until a behavioral bed becomes available. How are hospitals responding? The survey highlights two strategies, including using telemedicine for ED behavioral care and developing separate ED areas for patients with specialized needs. Of the respondents who have deployed or plan to deploy telemedicine, 40% plan to use telemedicine for behavioral health consults. At the same time, 32% of respondents expect to be using specialized needs areas to improve ED efficiency during the next three years. The survey points to other strategies that hospitals are using to improve ED efficiency, including reducing ED visits by expanding the use of urgent care clinics and increasing care coordination among physicians, case managers, and social workers. Reflecting the impact of healthcare reform, the survey also shows a decrease in the percentage of respondents expecting more uninsured/self-pay ED patients (down nine points, from 50% last year to 41% this year) and an increase in the percentage of respondents expecting ED operating margins to grow during the next three years (up 10 points, from 11% to 21%). These related findings are encouraging signs for all of us as we continue our drive to increase ED efficiency. PAGE 4

5 ANALYSIS Efficiency in the ED Through Managing Nonemergent Patients Michael Zeis HealthLeaders Media Senior Research Analyst Emergency departments are optimized to provide emergency care, of course. The timing of medical emergencies cannot be predicted, so EDs must be ready to provide care always. The open-door policy brings patients who need emergency care, patients who worry that they might need emergency care, and patients who don t need emergency care at all. This third category is resilient a fact of ED life. So, even though ED operations are designed for emergency care, they also must optimize the activities that support patients who do not need emergency care. While the effective handling of patients with emergent conditions remains a principal focus, to deliver that care, EDs need techniques to be effective with nonemergent patients, as well. Optimize the whole flow Transferring patients to inpatient floors is identified as a top bottleneck for in-ed flow by 70%, the item mentioned most frequently (Figure 3). Although EDs have a variety of tactics for accommodating patients pending their move to an inpatient bed, the presence of such bottlenecks is inevitable, and their resolution often requires active participation by other hospital departments. Of course, there are cases where additional ED capacity or additional inpatient beds are required, but more often, capacity is not the issue, says Trisha Cassidy, chief strategy officer for AMITA Health, whose facilities include four hospitals, a center for behavioral health, and seven immediate care centers in the northwest suburbs of Chicago. My hunch is that in most of the country there s not a shortage of inpatient beds. There may be a flow issue of when discharges happen, or when ED admissions happen, but I think that s probably a utilization issue as opposed to a capacity issue. At the top of the list of techniques for managing ED throughput are fast-track or split flow for low-acuity patients (67%), streamlined registration for arriving patients (57%), and direct or immediate bedding (51%) (Figure 5). Daniel Nadworny, RN, MSN, clinical director of operations for ED and urgent care at Beth Israel Deaconess Medical Center in Boston, with 672 licensed beds and approximately 1,250 fulltime and part-time physicians, sees these high levels of response as indications of widespread attention to the whole ED patient flow, instead of intense focus on freeing ED beds via transfer to inpatient floors or discharge from the ED. PAGE 5

6 He says, For so long, it was just get them out, get them out. Now, we re looking at how we have opportunities to improve from start to finish. The focus for a long time had been on disposition. But now we re being thoughtful of the whole process. Giving attention to those with special needs Faced with an increasing population of Medicare patients, in July of 2013, AMITA Health, Elk Grove Village, Illinois, redesigned its ED to enhance the experience of senior citizens. Says Cassidy, The ED experience can be very difficult for anybody, but for seniors in particular. Early in the planning process, AMITA Health Elk Grove Village investigated opening an ED specifically for seniors. We determined that a better approach would be to make the entire ED senior-friendly so that we didn t have to segregate senior patients from other incoming patients. The things that would be better for seniors would be better for everyone. Among the changes AMITA Health Elk Grove Village implemented were noise abatement, softer lighting, and no-glare finish on floors. In patient rooms, clock faces have large numbers, call lights have large buttons, and rooms are equipped with widescreen TVs that are easier to view. AMITA Health Elk Grove Village equipped all ED beds with softer, thicker mattresses, better for elderly patients with fragile skin. Efficiency was the motivation behind the decision to extend senior-friendly features to the entire ED. Rather than have specific rooms for seniors that might not be used part of the time, Cassidy explains, We decided to make every room able to accommodate seniors, so we can use the rooms interchangeably. Changes were made to patient interactions with the care team as well, and patient flow was modified to reduce triage time. WHAT HEALTHCARE LEADERS ARE SAYING Here are selected comments from leaders on how to ensure success in launching a telemedicine application in the ED. You need to have 24/7 access with immediate transfer capabilities. CEO for a small hospital Access to the appropriate provider must be assured. If it is spotty, then it will fail. Chief financial officer for a small health system Key factors are the credentialing of the specialists used to view the patient via telemedicine and the ability of the specialists to be compensated for their time and liability. Chief financial officer for a medium hospital You need to ensure that the support areas such as imaging and IT are on board from the very beginning and that they are available to troubleshoot when the need arises. Chief nursing officer for a small hospital There needs to be adequate training and access to equipment, as well as adequate understanding of the mutual obligations of both the ED and telemedicine providers. Chief medical officer for a small hospital You need to have buy-in and support from current medical staff. Chief operations officer for a small hospital Connectivity is the most important thing. Second is ensuring that providers and staff are fully trained in the operation of the equipment. Director of emergency services for a large hospital PAGE 6

7 Although AMITA Health Elk Grove Village initially investigated establishing an area designed specifically for a patient group with specialized needs, the organization arrived at a set of enhancements that it implemented throughout the ED. But survey results show that the use of specialized areas is increasing. Figure 6 shows that, in the three-year time frame, 55% of healthcare leaders expect their organizations to be using observation areas to improve ED throughput efficiency, an increase of 13 percentage points over the current measure of 42% (Figure 5). And onethird (32%) expect to be using ED areas for patients with special needs, an increase of 11 points over the present 21% measure. Cassidy notes that pediatric patients, behavioral health patients, and geriatric patients may have better experiences in an ED environment tailored to their needs. She asks, Do you need a psychiatric area in your ED? You would create a calmer, more private setting maybe a little more comfort, less agitation. I really can t imagine the discomfort of a psychiatric patient who comes into a typical ED environment that is so frenetic, with the lights bright and where there is a lot of noise. Indeed, patients with behavioral health problems present a set of problems that remain challenging for most emergency departments. Among the top factors contributing to ED bottlenecks for 62% of respondents are behavioral health patients (Figure 3), the bottleneck mentioned second most frequently. More than one-third (35%) say that accommodating mental health patients is their No. 1 challenge, while 70% include mental health patients among their top three challenges (Figure 2). Part of the problem, says Nadworny, is that both mental health and substance abuse are chronic diseases, plain and Patients are beginning to recognize the difference in the bill if they go to the ER or if they go to a doctor s office. simple. And as with any chronic disease, we in emergency medicine can do our role, but what is needed is a long-term solution and long-term care for these patients. Unlike many ED patients, for behavioral health patients, treatment does not necessarily begin once a determination is reached. Nadworny explains, Behavioral health patients may meet requirements for inpatient psychiatric care, but there may not be beds available in the region. Or they need to be plugged in with community-based providers, and there may not be enough of them. It s not like other conditions in the ED. If you have abdominal pain and there are five other people who come in with abdominal pain, we can deploy more resources. We own that. With behavioral health, for the most part, we re actually limited on who can help us with that. Telemedicine: expect more applications Trisha Cassidy Nearly half of respondents (49%) use telemedicine in EDs now, and another 11% expect to begin using telemedicine within three years (Figure 7). Among those using telemedicine in their EDs now, the top applications are for neuro/stroke consults (79%) and for behavioral health consults (40%) (Figure 8). Cassidy says neuro/stroke consults top the list of applications because of the six-hour time frame for making sure that stroke patients have access to treatment. That need for quick assessment and action often precludes moving a patient to a facility with on-staff PAGE 7

8 neurologists or stroke specialists. It could be very difficult to get a patient in and out of an ER to another hospital within that six-hour window. Nadworny expects that increased deployment will broaden telemedicine s applications. I see telemedicine really pushing more into prevention of ED visits and prevention of hospitalization. One area we probably will see it growing is with our skilled nursing facilities, long-term care facilities, nursing homes, and skilled rehabs. These are facilities that don t need a provider on-site all the time. But when somebody is having an issue, you really want a provider to be part of the consultation, and it s so hard to do that over the phone. Addressing avoidable ED visits More than half of respondents (59%) include coordinating with primary care providers among their tactics for minimizing avoidable visits to their EDs, the item mentioned most frequently (Figure 10). While a common tactic is for care coordinators or other ED staff to help find a provider for those without a primary care physician, Nadworny notes that a primary care provider/patient relationship may not be enough. Lack of availability of the primary care physician is behind some avoidable visits. uite often I see that a patient has called the primary care physician, but appointments are not available, so the patient is referred to the emergency room. If your first decision point is that the patient doesn t need the emergency room, but then the reason for sending the patient to the emergency room is there isn t an available primary care appointment, then that s a missed opportunity. More than half (53%) rank primary care physicians first in effectiveness in helping patients make more appropriate use of EDs (Figure 14). But the effect primary care providers Urgent care is not only a point of care but also a point of entry to the organization. Daniel Nadworny, RN, MSN may have on helping patients make appropriate use of the ED may be diminished, as mentioned earlier, by the lack of primary care availability and by recommendations to visit the ED that are sometimes offered when a timely appointment is not possible. For 42% of survey respondents, urgent care centers are among the tactics used to minimize avoidable ED visits (Figure 10). Says Cassidy, When low-acuity patients go there instead of the ED, it takes a population that probably doesn t really need the ED out of the ED. At AMITA Health, urgent care centers coordinate closely with primary care. In our system, she says, the urgent care clinics are connected to a primary care office. They do everything they can to make sure that the patients who come to urgent care have a primary care physician. Nadworny notes that the urgent care center can place a patient on a path of coordinated care. Our urgent care providers are making decisions not only for the condition of the moment, but also decisions about how to plug that patient into the healthcare system. That gives us a new benefit. Urgent care is not only a point of care but also a point of entry to the organization. So that person now is getting not just the urgent care coverage, but they re getting introduced into the network and getting more definitive care set up for them. PAGE 8

9 Patient knowledge, patient preference Four-fifths (81%) of healthcare leaders from organizations with urgent care clinics or that are planning urgent care clinics say that the need to provide a setting for patients with nonemergent conditions is among their top motivations for pursuing an urgent care clinic (Figure 13). More than half (52%) say they want to improve access through extended hours. In January 2016, Beth Israel Deaconess urgent care centers added appointment capability to their websites. With the intent of working with a relatively low volume of use in the early weeks of deployment, Beth Israel did not promote the capability. Even so, Nadworny says, during the first two months, 20% of all of our urgent care patients were going through our online system. Patients are becoming good consumers when it comes to nonemergent conditions. They know or at least think that they don t need the emergency room, and they are making the decision they feel is right for them. Patients now have more options available than they used to. If you go back 10 years, you could see your primary care doctor, or you could go to the emergency room, or you could wait it out. The broader trend behind taking advantage of additional care settings and paying more attention to care coordination is that providers are helping patients to become more aware of their choices. So both patient and provider play a role in the patient receiving care in the appropriate setting. Compared to last year s survey, there are decreases in the percentages of healthcare leaders who expect increases in uninsured/self-pay (50% to 41%, down nine points) and nonemergent ED patients (45% to 32%, down 13 points) (Figure 9). Cassidy observes two dynamics at work: A couple of things are happening now that a significant number of patients In our system, the urgent care clinics are connected to a primary care office. They do everything they can to make sure that the patients who come to urgent care have a primary care physician. Trisha Cassidy who were uninsured are now on the exchange. Number one, some are learning how to use their health insurance and are calling a primary care physician instead of going to the ER. When you re not insured, it s not always easy to get a physician appointment. Second, insured patients see a difference in out-of-pocket costs, as well. Patients are beginning to recognize the difference in the bill if they go to the ER or if they go to a doctor s office. AMITA Health assigns case managers to at-risk cohorts. Says Cassidy, For our managed populations, we have care coordinators assigned to the high-risk patients. For those patients who present in the ED or have shown up in the ED multiple times, the case managers have a regular dialogue with them after that. More than one-third of respondents (38%) coordinate with community social services to minimize avoidable ED visits (Figure 10). The ED staff at Penrose-St. Francis, which operates Penrose Hospital and St. Francis Medical Center with 522 licensed beds combined as well as four urgent care centers in the Colorado Springs area, holds quarterly meetings with a task force of community-based resources. PAGE 9

10 Says Cynthia Latney, PhDc, MSN, RN, NE-BC, chief nursing officer and vice president of patient care services, There is a community task force consisting of agencies for mental health, substance abuse, and other community resources. We come together on a quarterly basis so our hospitals and community leaders can talk about how to share resources, how to communicate, and how to enhance transfer of patients. When it comes to efficiency and patient flow, emergency departments will never lose their focus on the importance of transferring patients from the ED through admitting and onto an inpatient floor. But the attention that healthcare leaders are paying to care alternatives, case management, and care coordination indicates that ED decision-makers are examining the supply side of patient flow as well. Latney says, Penrose-St. Francis Health Services key focus areas are care coordination and transition of care. We re educating staff and our physicians on what we mean by care coordination and the role each team member is accountable for. When we re talking about practicing at the top of license, how do we maximize each other s We come together on a quarterly basis so our hospitals and community leaders can talk about how to share resources, how to communicate, and how to enhance transfer of patients. roles? At Penrose-St. Francis, It s making sure we have our case managers and social workers in our emergency departments, working side by side with the physician and nurses to assist with transitioning our patients to the next level of care. Michael Zeis is senior research analyst for HealthLeaders Media. Cynthia Latney, PhDc, MSN, RN, NE-BC PAGE 10

11 FIGURE 1: Annual Visits to ED What is the approximate number of annual patient visits to your ED? 28% 23% 21% 8% 8% 10% 30,000 or fewer 30,001 50,000 50,001 70,000 70,001 90,000 90, ,000 More than 110,000 Base = 212 More than one-quarter (26%) of survey respondents report that their EDs see in excess of 70,000 visitors annually. On the low-volume side, 28% say their EDs receive 30,000 or fewer visitors annually. As one would expect, ED volume is related to net patient revenue: 26% of organizations with $1 billion or more in net patient revenue see more than 110,000 patients in their ED annually. And 42% of organizations with net patient revenues below $250 million experience 30,000 or fewer annual patient visits in their EDs. PAGE 11

12 FIGURE 2: ED Challenges Please rank the top three challenges facing your ED. Net Top 3 1st Rank Accommodating mental health patients 70% 35% Shortage of inpatient beds 42% 20% Wait times 42% 10% In-ED patient flow 35% 13% Patient flow external to ED 34% 12% Accommodating opioid/substance abuse patients 32% 3% Accommodating nonemergent patients 29% 5% Accommodating patients with chronic diseases 15% 1% Base = 212 That EDs have difficulty with mental health patients is clear: More than one-third (35%) say that accommodating mental health patients is their No. 1 challenge, and 70% include mental health patients among their top three challenges. The item mentioned next in frequency is the shortage of inpatient beds, the top problem for 20% and among the top three for 42%. The high position of the inpatient bed problem is an example of how optimizing ED efficiency can be seen as an organizationwide activity. PAGE 12

13 FIGURE 3: Bottleneck Problems for ED Flow Please select the top three factors that present bottleneck problems for in-ed flow. ED-to-inpatient transfers 70% Behavioral health patients occupying ED beds 62% Delays in specialist response Lack of fast-track for low-acuity patients Delays in completing tests, diagnostic procedures Delays in reading or interpreting test results Delays in hospitalist response Inadequate ED staff 33% 31% 25% 20% 19% 15% Base = 212, Multi-Response Nearly three-quarters (70%) include ED-to-inpatient transfers among their top three reasons for stalled ED flow. Behavioral health patients occupying ED beds is the item mentioned second most frequently, by 62%. Both factors essentially diminish ED capacity as patients await the next steps in their care. PAGE 13

14 FIGURE 4: Average Time Between Decision to Admit and Time Patient Leaves ED What is the average number of minutes between the decision to admit a patient and the time the patient leaves the ED? 29% 20% 23% 19% 10% Base = 153 Average number of minutes = 141 One-fifth (20%) of the ED s patients who are to be admitted are moved out of the ED less than an hour after the decision to admit is made. For another one-fifth (19%), the delay after a decision is made to admit the patient is four hours or more. The average wait time is 141 minutes between the decision to admit a patient and the time the patient leaves the ED. PAGE 14

15 FIGURE 5: Operations Techniques to Increase ED Throughput Please identify the operations techniques your organization uses now to help optimize ED throughput efficiency. Fast-track or split flow for low-acuity patients 67% Streamlined registration for arriving patients Direct or immediate ED bedding 51% 57% Structural improvements to ED, improved facility Observation areas Improved labs, imaging 38% 42% 42% Frequent ED team huddles ED areas for patients with specialized needs 21% 26% None 1% Base = 212, Multi-Response Common techniques for managing ED throughput include fast-track or split flow for lowacuity patients (67%), streamlined registration for arriving patients (57%), and direct or immediate ED bedding (51%). However, EDs are highly individualized, and must use a set of flow-optimization tools that are appropriate for the hospitals they are part of, and are appropriate for the characteristics of the population they serve. PAGE 15

16 FIGURE 6: Operations Techniques to Optimize ED Throughput Next Three Years Please identify operations techniques that your organization expects to be using within three years to improve ED throughput efficiency. Fast-track or split flow for low-acuity patients 75% Streamlined registration for arriving patients Direct or immediate ED bedding Observation areas Structural improvements to ED, improved facility 63% 56% 55% 52% Improved labs, imaging 45% Frequent ED team huddles ED areas for patients with specialized needs 32% 36% Base = 212, Multi-Response Within three years, 75% will have a fast-track for low-acuity patients, an increase of eight percentage points over the current 67% (Figure 5). In the three-year time frame, observation areas show the largest gain, moving to 55% from a present level of 42%, an increase of 13 points. One-third (32%) expect to be using ED areas for patients with specialized needs, an increase of 11 points over the present 21% measure. Healthcare leaders are focusing on patients with conditions that delay progress through the ED for other patients by implementing tactics to accommodate such patients outside of the main ED patient flow. PAGE 16

17 FIGURE 7: Status of Telemedicine Deployment in the ED What is your organization s status regarding deployment of telemedicine in the ED? 33% 25% 16% 11% 8% 8% Use already, fully deployed Use already, additional deployment planned Usage planned within three years Investigating Do not plan to use Don't know Base = 212 Nearly half of respondents (49%) use telemedicine in EDs now, with 33% planning additional deployment. Another 11% expect to use telemedicine within three years, and one-quarter are still investigating. The benefits of the technology are apparent, and it is just a matter of time until it becomes a standard ED resource. PAGE 17

18 FIGURE 8: Principal Telemedicine Applications in ED What are the principal applications for telemedicine in your ED? Specialty neuro/stroke consults 79% Behavioral health consults 40% Remote diagnosis via diagnostics interface Patient monitoring in lieu of bedside observers Specialty surgery consults Pediatric consults Burn consults Don't know 17% 14% 10% 6% 4% 1% Base = 125, Multi-Response Among those who have deployed telemedicine in the ED or plan to within 3 years By far, the telemedicine application mentioned most frequently is specialty neuro/stroke consultations (79%). The second most common use is for behavioral health consults (40%). However, telemedicine has broad applications. Among the other uses respondents told us about are pediatric consults (mentioned by 6%) and burn consults (mentioned by 4%). PAGE 18

19 FIGURE 9: Expected ED Area Increases Next Three Years For which of the following is your organization expecting an increase within the next three years? ED patient volume 70% 78% ED quality outcomes 63% 64% Volume of hospital admissions from the ED 46% 48% Insured patients not paying deductible/copay 45% 45% Uninsured/self-pay ED patients 41% 50% Newly insured with nonemergent conditions 39% NA Percentage of nonemergent ED patients 32% 45% ED operating margin 21% 11% None 1% 2% Base Multi-Response Nearly three-quarters (70%) expect ED patient volume to increase within the next three years. And nearly two-thirds (63%) expect ED quality outcomes to increase. One-third (32%) say that they expect the percentage of nonemergent patients to go up over the next three years, a measure that is down from 45% who said last year they expected increases. This year the percentage who expect increases over three years in uninsured or self-pay patients has declined also, from 50% last year to 41% now. This year, 21% expect ED operating margins to increase, compared to 11% who expected an increase last year. PAGE 19

20 FIGURE 10: Tactics to Minimize Avoidable ED Visits Which tactics does your organization use to minimize avoidable visits to your ED? Coordinate with primary care providers Limit prescriptions for opioids Coordinate with ambulatory/outpatient clinics 50% 56% 59% Open an urgent care clinic Coordinate with community social services Assign case managers, social workers to individuals Track those seeking opioid prescriptions Coordinate with postacute care providers Assign case managers, social workers to cohorts 42% 38% 38% 36% 33% 29% Base = 212, Multi-Response Nearly two-thirds (59%) include coordinating with primary care providers among their tactics for minimizing avoidable visits to their EDs, the item mentioned most frequently. Nearly as many (56%) say limiting prescriptions for opioids is a tactic for minimizing avoidable visits. The third-most-mentioned item is coordinating with ambulatory and outpatient clinics (50%), which, like primary care, can affect both initial ED visits and repeat ED visits. PAGE 20

21 FIGURE 11: Status of Alternative Care Settings What is your organization s status regarding each of the following care settings? Convenient care clinics (often in big-box retail) Urgent care clinics (walk-in, extended hours) Freestanding EDs (full range of emergency care) We own 16% 51% 25% We partner 10% 8% 4% We have an informal working relationship 6% 8% 1% Plan within three years 4% 8% 2% Investigating 16% 11% 13% Not involved, not pursuing 28% 9% 32% Not applicable 19% 6% 22% Base = 212 Fifty-nine percent either own (51%) or partner (8%) with an urgent care clinic. Slightly more than one-quarter either own (16%) or partner with (10%) convenient care clinics. Twenty-five percent own and 4% partner with a freestanding ED. Because all three provide alternatives to the ED for those seeking care, and most of the time can provide care at lower costs, they represent care settings to consider as part of efforts to improve overall efficiency and effectiveness. PAGE 21

22 FIGURE 12: Care Setting With Most Potential to Improve Industry s Ability to Deliver Value-Based Care Of the three care settings, in your appraisal, which has the most potential to improve the industry s ability to deliver value-based care? 44% 36% 13% 8% Convenient care clinics Urgent care clinics Freestanding EDs Don't know Base = 212 A higher percentage of healthcare leaders say that urgent care centers have the most potential to improve the industry s ability to deliver value-based care (44%) than those who say convenient care clinics have the most potential (36%). But the percentages are close, indicating that both settings are expected to be important to the industry s value-based future. PAGE 22

23 FIGURE 13: Motivations for Pursuing Urgent Care Clinic Which of the following are among your top three motivations for pursuing an urgent care clinic? Address patients with nonemergent conditions 81% Reduce ED crowding 63% Improve access via extended hours 52% Broaden market reach 38% Maximize in-network patient visits 18% Improve ED payer mix Provide high-margin ancillary services Broaden the range of services offered 9% 8% 6% Don't know 1% Base = 157, Multi-Response Among those with or planning an urgent care clinic Among those with or planning an urgent care clinic, top among the motivations is to provide a setting to address the needs of patients with nonemergent conditions (81%). The item mentioned second most often is related, no doubt: to reduce ED crowding (63%). More than half (52%) are pursuing urgent care centers to improve access through extended hours. Business issues are part of the mix, with 38% including the desire to broaden market reach among their top motivations. PAGE 23

24 FIGURE 14: Provider/Service Effectiveness in Helping Patients Make Appropriate Use of ED Please rank the following care continuum providers or services according to their effectiveness in helping patients make more appropriate use of your organization s ED. Net Top 3 1st Rank Primary care physicians 79% 53% Urgent care centers 54% 16% Behavioral health services 42% 8% Community-based clinics/fhcs 40% 10% Convenient care clinics 28% 5% Social services 25% 4% Skilled nursing facilities 15% 2% Home health 15% 1% Base = 210 There is wide understanding of the role for the primary care physician in helping patients make more appropriate use of EDs. More than half (53%) rank primary care physicians first in effectiveness in helping patients make more appropriate use of EDs. And 79% include primary care physicians among the top three care continuum providers in effectiveness. In comparison, only 16% rank urgent care centers first in effectiveness in helping patients make more appropriate use of their EDs, while 54% include urgent care centers in their top three. PAGE 24

25 METHODOLOGY The 2016 ED Strategies Survey was conducted by the HealthLeaders Media Intelligence Unit, powered by the HealthLeaders Media Council. It is part of a series of monthly Thought Leadership Studies. In February 2016, an online survey was sent to the HealthLeaders Media Council and select members of the HealthLeaders Media audience. A total of 212 completed surveys are included in the analysis. Base size varies between 153 and 212 depending on whether respondents had the knowledge to provide an answer to a given question. The margin of error for a base of 212 is +/-6.7% at the 95% confidence interval. ADVISORS FOR THIS INTELLIGENCE REPORT The following healthcare leaders graciously provided guidance and insight in the creation of this report. Trisha Cassidy Chief Strategy Officer AMITA Health Arlington Heights, Illinois Cynthia Latney, PhDc, MSN, RN, NE-BC CNO and Vice President, Patient Care Services Penrose-St. Francis Health Services Colorado Springs, Colorado Daniel Nadworny, RN, MSN Clinical Director of Operations ED and Urgent Care Beth Israel Deaconess Medical Center Boston ABOUT THE HEALTHLEADERS MEDIA INTELLIGENCE UNIT The HealthLeaders Media Intelligence Unit, a division of HealthLeaders Media, is the premier source for executive healthcare business research. It provides analysis and forecasts through digital platforms, print publications, custom reports, white papers, conferences, roundtables, peer networking opportunities, and presentations for senior management. Intelligence Report Senior Research Analyst JONATHAN BEES jbees@healthleadersmedia.com Executive Vice President ELIZABETH PETERSEN epetersen@blr.com Publisher CHRIS DRISCOLL cdriscoll@healthleadersmedia.com Editorial Director BOB WERTZ bwertz@healthleadersmedia.com Intelligence Unit Director ANN MACKAY amackay@healthleadersmedia.com Assistant Managing Editor ERIKA BRYAN ebryan@healthleadersmedia.com Custom Media Sales Operations Manager CATHLEEN LAVELLE clavelle@healthleadersmedia.com Intelligence Report Contributing Editor JENNIFER THEW, RN jthew@healthleadersmedia.com Intelligence Report Design and Layout KEN NEWMAN Intelligence Report Cover Art DOUG PONTE dponte@healthleadersmedia.com UPCOMING INTELLIGENCE REPORT TOPICS JUNE Strategic Cost Control JULY Value-Based Readiness Copyright 2016 HealthLeaders Media, a division of BLR, 100 Winners Circle, Suite 300, Brentwood, TN Opinions expressed are not necessarily those of HealthLeaders Media. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. AUGUST Patient Experience HEALTHLEADERS MEDIA C uncil Access. Insight. Analysis. Click for information on joining. PAGE 25

26 RESPONDENT PROFILE TITLE Respondents represent titles from hospitals and health systems. Base = 212 TYPE OF ORGANIZATION Base = 212 Hospital 69% Health system (IDN/IDS) 31% NUMBER OF BEDS Base = 147 (Hospitals) % % % NUMBER OF SITES Base = 65 (Health systems) 39% Clinical leaders 36% Senior leaders 15% Operations leaders 5% Marketing leaders 3% Financial leaders 1% Information leaders % % % SENIOR LEADERS CEO, Administrator, Chief Operations Officer, Chief Medical Officer, Chief Financial Officer, Executive Dir., Partner, Board Member, Principal Owner, President, Chief of Staff, Chief Information Officer, Chief Nursing Officer, Chief Medical Information Officer CLINICAL LEADERS Chief of Cardiology, Chief of Neurology, Chief of Oncology, Chief of Orthopedics, Chief of Radiology, Dir. of Ambulatory Services, Dir. of Clinical Services, Dir. of Emergency Services, Dir. of Inpatient Services, Dir. of Intensive Care Services, Dir. of Nursing, Dir. of Rehabilitation Services, Service Line Director, Dir. of Surgical/ Perioperative Services, Medical Director, VP Clinical Informatics, VP Clinical uality, VP Clinical Services, VP Medical Affairs (Physician Mgmt/MD), VP Nursing OPERATIONS LEADERS Chief Compliance Officer, Chief Purchasing Officer, Asst. Administrator, Chief Counsel, Dir. of Patient Safety, Dir. of Purchasing, Dir. of uality, Dir. of Safety, VP/Dir. Compliance, VP/Dir. Human Resources, VP/Dir. Operations/Administration, Other VP FINANCIAL LEADERS VP/Dir. Finance, HIM Director, Director of Case Management, Director of Patient Financial Services, Director of RAC, Director of Reimbursement, Director of Revenue Cycle MARKETING LEADERS VP/Dir. Marketing/Sales, VP/Dir. Media Relations INFORMATION LEADERS Chief Technology Officer, VP/Dir. Technology/MIS/IT REGION 17% 36% 33% 14% WEST: Washington, Oregon, California, Alaska, Hawaii, Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming MIDWEST: North Dakota, South Dakota, Nebraska, Kansas, Missouri, Iowa, Minnesota, Illinois, Indiana, Michigan, Ohio, Wisconsin SOUTH: Texas, Oklahoma, Arkansas, Louisiana, Mississippi, Alabama, Tennessee, Kentucky, Florida, Georgia, South Carolina, North Carolina, Virginia, West Virginia, D.C., Maryland, Delaware NORTHEAST: Pennsylvania, New York, New Jersey, Connecticut, Vermont, Rhode Island, Massachusetts, New Hampshire, Maine PAGE 26

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