Disclosures. Non urgent ED visits. Learning Objectives % of ED visits by children are for non urgent care. Initial Research

Transcription

1 39 th National Conference on Pediatric Health Care How to Keep your Patients out of the Emergency Department: What Acute Care and Primary Care Nurse Practitioners Can Do March 19-22, 2018 CHICAGO Disclosures The presenters have no disclosures Mary Jean Ohns DNP, APRN, CPNP, CCRN & Tonya Schmitt DNP, APRN, CPNP Learning Objectives Describe the impact non urgent emergency department use has on quality of health care, patient outcomes, and cost to the health care system Identify the demographics of those who use the emergency department non urgent care Recognize the complex, multifactorial nature of non urgent emergency department use by pediatric patients Design at least three practice/practice setting changes to address the issue of non urgent emergency department use Non urgent ED visits 58 85% of ED visits by children are for non urgent care (Berry, Brousseau, Brotanek, Tomany Korman, & Flores, 2008; Cohen et al., 2013) Common Childhood Illnesses Cold symptoms are the most common reason for emergency department visits by children: Chills FEVER Cough Congestion Sneezing Sore throat Initial Research Initial studies focused on identifying characteristics of those who use the ED for non urgent care (CDC: National Center for Health Statistics, 2013; Swavely, Baker, Bilger, Zimmerman, & Martin, 2015) 1

2 Identified Population Low health literacy Identified PCP for their child Public Insurance Health Literacy Health literacy measures a person s ability to obtain, process and understand basic health information and then use that information to make informed and appropriate healthcare decisions If parents lack the ability to determine the severity of their child s symptoms, they are more likely to seek immediate health care ED (Yoffe, et al., 2011) Low Health Literacy Over half of caregivers who bring their children to the ED have: low health literacy frequently seek care for non urgent issues Low health literacy caregivers have 3 times greater odds of presenting for a non urgent condition than those with adequate literacy Primary Care Provider Up to 95% of children who come to the ED for non urgent care have a primary care provider (Kubicek et al., 2012) (Morrison, Schapira, Gorelick, Hoffmann, & Brousseau, 2014) Public Health Insurance In 2012, children with Medicaid coverage were more likely than uninsured children and those with private coverage to have visited the emergency room (ER) at least once in the past year. The History of Non Urgent ED Use 1950s public s view of the ED began to change 1960s research regarding ED visits (CDC: National Center for Health Statistics, 2014) 1970s ED used as source of non urgent care (Krug, 1999) The last half of the 20 th century saw a 600% increase in ED visits (National Center for Health Statistics, 2000) 2

3 Unfavorable Consequences Overcrowding Long wait times Increased cost Poor health outcomes Lack of continuity of care Lack of follow up Impact on the ED Nationally, EDs are the most common site of acute care visits When care in the ED is disconnected from the patient s primary source of care, the outcomes can include duplication of tests, lack of follow up, and an increased risk for medical errors (Pitts, et al., 2010) (Brousseau, et al., 2007) Increased Healthcare Cost On average, an ED visit for non urgent care costs seven times more than care at a community health center An ED visit of low complexity is reimbursed under Medicaid, $18.12; while the same level of service is reimbursed $36.70 under Medicare, a 49.4% reimbursement rate (Government Accountability Office, 2011) Impact on Primary Care Con nuity ED care: Do not have access to patient s medical record Focus is on immediate need an cipatory guidance preven ve educa on follow up from previous visits development of ongoing rela onship (Rosenzweig, 1993) Impact on Primary Care Quality Children receive recommended care only 46% of the time (Mangione Smith et al., 2007) State of the Science Descriptive studies Population identified Resulting issues identified: non emergent issues are handled less effectively and more expensively in the ED 3

4 Interventional Studies: State of the Science Revision of PCP Prac ces Access Access to Care About 75% of children s visits to an ED in the past 12 months took place at night or on a weekend, regardless of health insurance coverage status Educa on Health Literacy (CDC: National Center for Health Statistics, 2014) State of the Science Interventional studies Revised PCP services: same day appointments walk in visits convenient hours effective telephone triage answering services (Brousseau, et al., 2007; Sturm, et al., 2010) Educational Intervention The pediatric after hours non life and death almost an emergency booklet 22 page booklet written at a 4.2 grade reading level First Study Reduction in ED visits ranged from 55% 81% (p <0.001) (Yoffe, et al., 2011) Second Study Study group showed a significantly lower use of ED services (p <0.05) (Yoffe, McClellan, Tolson, Moore, & McKay, 2012) Interventional Studies Education Access to Care Guide: Creation of document to summarize office policies and procedures for families Parent Education Toolkit on Fever: RN fever teaching at newborn, 5 weeks and 2 month well visit or any other age group as requested by provider Office Video Education while Waiting: Creation of office video to educate about common concerns that can be addressed at home or in the office (Cohen, Barton, Brennan, & Chen Lim, 2013) 24 Hour Nurse Call Line Since the 1990s, telephone triage services aimed at decreasing unnecessary ED visits have been found to: Be cost effective Provide quality triage Increase parent / provider satisfaction (Bunik, et al., 2007) 4

5 The Bottom Line So What Do We Do Now? An effort to access to care has resulted in: Fragmented Care Poor health outcomes Lack of continuity of care Increased health care costs Role of the Primary Care Pediatric Nurse Practitioner Role of the Acute Care Pediatric Nurse Practitioner How to Frame the Problem Donabedian s Matrix for the Classification of Quality Measures Applied to Non urgent use of the ED by pediatric patients According to Donabedian In practice, lower quality and inefficiency coexist, because wasteful care is either directly harmful to health or is harmful by displacing more useful care. ED vs. PCP for non urgent care Orem s Theory of Dependent Care (Donabedian, 1988, p. 1745) According to Donabedian Inefficiency is judged by the degree to which expected improvements in health are achieved in an unnecessarily costly manner. access to care ED u liza on cost of care (Donabedian, 1988, p. 1745) Methods Teaching Guiding Supporting Child BCFs age, gender developmental / health state, environmental factors, family systems, patterns of living, resource availability Theory of Dependent Care Nursing Agency Dependent Care Deficit = need for nursing Self Care Requisites Universal air, water, food, elimination hazards, activity /rest solitude / social interaction normalcy Relationship between abilities of parent to care for child and the needs or demands of the child Health Deviation Needs due to illness / injury Developmental Maturational changes in the life cycle Dependent Care Agent Caregiver Capabilities for specific dependent care: Ability to judge and decide what to do Power Components: Knowledge, Attitude, Skill, Motivation Foundational Capabilities and Dispositions: interests / values / ability to remember directions Parents wish to care for their children DCA Orem, 1995; Taylor et al.,

6 Health Literacy Change the way health information is designed and delivered Simply designating a reading grade level for print materials is not effective Materials must be redesigned using best practices to reduce health literacy demands and match consumer preferences Periodic testing of materials with the intended consumers is essential (U.S. DHH, 2008) Research / Practice Changes Complex, multi factorial issue Address in both acute and primary care settings Combine interventions discussed in the literature to determine effectiveness Financial incentives in the Medicaid insured pediatric population Study educational options with low health literacy demands Target Medicaid patients for care management: frequent users vs. children < 1 year of age (Christensen, Kharbanda, Velden, Payne, 2017) Primary Care PNP Continuity of Care Rela onships with caregivers value continuity of care Identify high risk population Reinforce appropriate use of ED Enhance access to care Assess caregivers abilities and individualize interventions Theory of Dependent Care Identify resources that empower caregivers Provide a consistent message throughout the office (Ohns, Oliver McNeil, Nantais Smith, & George, 2016) Increase Primary Care PNP parental knowledge related to management of common childhood health concerns and value continuity of care from a consistent provider Clinical Practice Example Number of ED/UC visits September 2017 through January 2018: Cost of ED visit vs. office Most frequent diagnosis Poor follow up Can cause delay in treatment for some chronic issues Why were services outsourced? Patient or provider initiated? Do the providers even know its happening? Then Why? 6

7 Case Scenario 15 year old seen in community ED for sore throat Treated with antibiotics with negative rapid strep test, plan based on clinical appearance 3 days later developed secondary rash.same ED treated with high dose steroids, changed antibiotics One week later presents to PCP with severe fatigue, joint pain, residual rash Primary Care PNP Access to Care Educate caregivers regarding access to care, prescription refills Well and sick appointments, evening / weekend hours, same day / walk in appts, phone triage, PCP on call Chronic illness = action plan + meds Educate regarding after hours options Call office before going to ED Clinical Example 6 year old presents to urgent care with complaints of cough, congestion, clear nasal drainage and tactile temperature for 2 days Diagnosis: sinusitis Treatment: Zithromax daily for 5 days Tylenol with codeine for cough Decongestant Liquid albuterol Primary Care PNP Education = Empower Caregivers Keep certain OTC meds at home Anticipatory guidance for well / sick visits Teach fever management with appropriate weight based dosing of antipyretics Primary Care PNP Consider additional services to offer in clinic: Rapid testing Straight catheterization IV hydration Suturing Casting Role of Acute Care PNP Identify the child s PCP If no PCP, provide resources to identify PCP Ask: Is PCP aware of current condition? Was PCP called prior to coming to ED? Discuss continuity of care = quality care 7

8 Role of Acute Care PNP Encourage follow up with PCP by phone or visit Written discharge instructions at appropriate literacy level Provide anticipatory guidance for current condition Provide prescriptions for OTC medications as covered by insurance Send written / computerized summary to PCP Focus Group Identify the high risk populations preferred method of education regarding common childhood illnesses Change the way health information is designed and delivered Simply designating a reading grade level for print materials is not effective Materials must be redesigned using best practices to reduce health literacy demands and match consumer preferences Periodic testing of materials with the intended consumers is essential (USDHHS, 2008) Educational Options References Berry, A., Brousseau, D., Brotanek, J., Tomany Korman, S., Flores, G. (2008). Why do parents bring children to the emergency department for non urgent conditions? A qualitative study. Ambulatory Pediatrics, 8, Brousseau, D., Hoffmann, R., Nattinger, A., Flores, G., Zhang, Y., & Gorelick, M. (2007). Quality of primary care and subsequent pediatric emergency department utilization. Pediatrics, 119(6), Bunik, M., Glazner, E., Chandramouli, V., Emsermann, C., Hegarty, T., Kempe, A. (2007). Pediatric telephone call centers: How do AAP EPIC After Visit Summary they affect health care use and costs? Pediatrics 119(2), e305 e313. doi /prds Center for Disease Control and Prevention (2013). National center for health statistics. health, United States:, 2012 with special feature on emergency care. Retrieved from: Christensen, E., Kharbanda, A., Velden, H., Payne, N. (2017). Predicting frequent emergency department use by pediatric Medicaid patients. Population Health Management 20(3), Cohen, R., Barton, S., Brennan, S., & Chen Lim, M (2013). Evaluation of Non Urgent Emergency Department Visits in a Pediatric Primary Care Population. Journal of Pediatric Health Care, 27(5), References Donabedian, A. (1988). The quality of care how can it be assessed? Journal of the American Medical Association, 260 (12), Government Accountability Office. (2011) Hospital emergency departments: Health center strategies that may help reduce their use. Washington, DC: GAO; Pub no. GAO R. Retrieved from: Kubicek, K., Liu, D., Beaudin, C., Supan, J., Weiss, G., Lu, Y., Kipke, M. (2012). A profile of nonurgent emergency department use in an urban pediatric Hospital. Pediatric Emergency Care, 28(10), Krug, S. (1999). Access and use of emergency services: Inappropriate use versus unmet need. Clinical Pediatric Emergency Medicine, 1(1), Mangione Smith, R., DeCristofaro, A., Setodji, C., Keesey, J., Klein, D., Adams, J., McGlynn, E. (2007). The quality of ambulatory care delivered to children in the United States. New England Journal of Medicine, 357(15), Morrison, A., Scharpira, M., Gorelick, M., Hoffman, R., & Brousseau, D. (2014). Low caregiver health literacy is associated with higher pediatric emergency department use and nonurgent visits. Academic Pediatrics, 14(3), National Center for Health Statistics (2000). National hospital ambulatory medical care survey, emergency department summary. Centers for References Ohns, M.J., Oliver McNeil, Nantais Smith, George, N., (2016). Nonurgent use of the emergency department by pediatric patients: A theory guided approach for primary and acute care pediatric nurse practitioners. Journal of Pediatric Health Care 30(4), Orem, D. (1995). Nursing: Concepts of practice (5 th ed.) St. Louis, MO, Mosby Year Book, Inc. Pitts, S., Carrier, E., Rich, E., & Kellermann, A. (2010). Where Americans get acute care: Increasingly, it s not at their doctor s office. Health Affairs, 29(9), Rosenzweig, S. (1993). Emergency rapport. Journal of Emergency Medicine, 11, Sturm, J., Hirsh, D., Lee, E., Massey, R., Weselman, B., Simon, H. (2010). Practice characteristics that influence non urgent pediatric emergency department utilization. Academic Pediatrics, 10(1), Swavely, D., Baker, K., Bilger, K., Zimmerman, D., & Martin, A. (2015). Understanding nonurgent pediatric emergency department visits using hospital and family centric data to inform system redesign. Journal of Nursing Care Quality 30(4), Disease Control. 8

9 References Taylor, S., Renpenning, K., Geden, E., Neuman, B., & Hart, M. (2001). A Theory of Dependent Care: A corollary theory to Orem s Theory of Self Care. Nursing Science Quarterly, 14(1), United States Department of Health and Human Services (2008). America's health literacy: why we need accessible health information. Retrieved from Yoffe, S., Moore, R., Gibson, J., Dadfar, N., McKay, R., McClellan, D.,& Huang, T. (2011). A reduction in emergency department use by children from a parent educational intervention. Family Medicine, 43(2), Yoffee, S., McClellan, D., Tolson, H., Moore, R., & McKay, R. (2012). Tired of seeing your patients in the ED? Let s give parent education another look! The Journal of Texas Medicine, 108(2), e1. 9