An Emergency Department (ED) Care Coordination Initiative
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1 An Emergency Department (ED) Care Coordination Initiative Cjloe Vinoya LDI SUMR Program Scholar Melissa Rodgers Projects Director, Center for Emergency Care Policy Research Karin Rhodes, MD, MS Director, Center for Emergency Care Policy Research
2 Case Studies
3 The Problem: Fragmented Medical Care Fragmented Care: Medical care in which there is little to no interaction between providers caring for the same patient * Older patients; patients with disabilities/chronic conditions Consequences Duplicate testing Conflicting care plans Higher costs Significant attention in the ACA Solution: Care Coordination *(Katz et al., 2012)
4 What is Care Coordination? the deliberate organization of patient care activities between 2/more participants (including the patient) involved in a patient s care to facilitate the appropriate delivery of healthcare services. (McDonald et al., 2007)
5 The role of the ED has been neglected. ED used when care coordination fails Co-pays are the reason why I haven t seen a specialist, so I come to the ED to get better. I came to the ED with hypertension because I haven t been taking my Lisinopril my PCP forgets to call the pharmacy for refills. I always seem to have complications during the weekends, when my regular doctors or transport team are not available.
6 The Overarching Questions What would an ED-based care coordination intervention look like? Would an ED-based care coordination intervention : Reduce return ED visits and hospital admissions/readmissions (and ultimately cut costs)? Increase follow-up visits to PCPs? Improve patient experience with emergency care?
7 Overview of Presentation Study Goals Methods Results Conclusions Limitations Looking Ahead Lessons Learned Acknowledgements
8 Study Goals
9 Current Questions What care coordination needs do ED patients and providers identify? Do providers and patients agree on needs for care coordination? Which, if any, interventions may be more or less effective?
10 Methods
11 Patient Assessment Survey Timeframe: 8 weeks (April 2013 August 2013) Collected by research assistants N = 476 surveys I am going to read you a list of services that some of our patients have said they need. Can you tell me which, if any, would be helpful to you? Help making follow up appointments Help getting prescribed medications Help managing your pain Transportation Stopping smoking Drug counseling Alcohol counseling Intervention for depression, anxiety or other mental health concerns Education about your medical condition Other, Please specify
12 Provider Assessment Survey Timeframe: 8 weeks (April 2013 August 2013) Collected in EMTRAC (at discharge) N = 12,499 surveys
13 Results What care coordination needs do patients identify? What care coordination needs do providers identify? Do providers and patients agree on needs for care coordination?
14 Patient Demographics (N=476) Female (57%) African-American (62%) Childless (57%) Employed (48%) Single/never married (50%) Income < $30,000 (54%) High school or less (41%)
15 Patients are identifying needs 349 surveys (73%) identified at least 1 service Help making follow-up appointments 38% Help getting medications 31% Pain management Transportation 39% 40% Stop smoking 16% Drug/Alcohol counseling 3% Mental health intervention 20% Health Education 32% % of Patients Interested
16 Provider Demographics N=12,499 surveys, 231 individual providers The majority of providers who answered the CC survey were residents (57%) and nurse practitioners (24%) 70% of all surveys indicated Don t Know or None 26% of all surveys indicated 1-2 services 4% of all surveys indicated 3 or more services
17 Providers are not identifying needs 3721 surveys (30%) identified at least 1 service Help making follow-up appointments 73% Help getting medications 18% Pain management Transportation Stop smoking Drug/Alcohol counseling Mental health intervention 9% 8% 6% 9% 8% Health Education 20% % of Providers Identifying Needs
18 Do patients and providers agree? 386 pairs Is there agreement on what services are needed? how many services are needed?
19 Patient/Provider Comparison of Identified Needs (n=386 pairs) Care Coordination Services Patient Identified Needs Provider Identified Needs Patient-Provider Service Needs Agreement N % N % N % Help making follow-up appointments % 84 22% 30 18% Help getting medications 89 23% 25 7% 10 10% Pain management % 14 4% 7 7% Transportation % 14 4% 7 6% Stopping smoking 45 12% 9 2% 2 4% Drug and/or Alcohol counseling 9 2% 10 3% 2 12% Mental health intervention 58 15% 3 1% 1 2% Health Education 91 24% 28 7% 7 6%
20 Patient/Provider Comparison of Identified Needs Patients Frequency % 22% 29% 7% 23% 26% 29% 12% 2% Providers Agreement 24% 15% 7% 20 4% 4% 2% 3% 1% 0
21 Distribution of Indicated Services (n=386 pairs) 80% 70% 71% 60% 50% 40% 30% 20% 28% 48% 23% 24% Patient Provider 10% 0% None/Don't Know 1-2 Services 3 or more Services 5%
22 If we were to target a specific group Target the majority Patients who indicated 1-2 services Of these 187 patients, the top 4 choices are: Help making follow-up appointments (26%) Education about medical condition (26%) Help managing pain (24%) Transportation (24%)
23 Conclusions
24 We can see that Patients identified a variety of service needs that are currently not being addressed. If we choose to pursue this: Should not rely on provider identification Service provision needs to be incorporated into system workflow Findings identify potential targets for care coordination that might improve the patients experience and health outcomes
25 Limitations
26 Limitations Convenience sample Single site; generalizability? Answers may vary in different situations: Hypothetical vs. Actual service provision Patient vs. Provider interpretation of what that service would look like Patient vs. Insurer vs. Hospital paying for services
27 Looking Ahead
28 Possible Next Steps Future studies Willingness to pay? Specific Service to target? Role of providers in ED Care Coordination? Automatic to PCP? Discharge Center Funding? ED vs. Hospital-wide? In-house vs. Outsource? Health outcomes to measure? Decrease admissions?
29 Lessons Learned
30 I learned How to make a presentation in one hour (not this one). That my job as a research assistant in the ED is coveted. Most patients come to the ED because they are sick. Actively listening and asking the right questions can open doors. Networking is the key to life.
31 Thank you!! Dr. Karin Rhodes Melissa Rodgers Fran Shofer Emergency Medicine staff IPD 509 Sarah Rottenberg Carolina Garzon Engineering/MBA students Penn medical students Albert Yu Leticia Daconti Charlotte Lawson SHIP Staff Joanne Levy and LDI SUMR scholars
32 Questions?
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