ED Care Triage: Linkage to Primary Care

ED Care Triage: Linkage to Primary Care BEST PRACTICES SUMMARY Updated 4/17/2017 ONECITY HEALTH SERVICES 199 Water Street, 31st Floor, New York, NY 10038

EXECUTIVE SUMMARY The goal of the ED Care Triage project is to improve care for patients treated and released from the Emergency Department (ED). The first of the three phases focuses on improving linkages to primary care in the ED. OneCity Health developed a five competency framework to assess primary care linkage: Correctly identify the patient s primary care provider (PCP) Determine at what time interval the appointment should be made Communicate the correct provider and time interval to the scheduler Schedule the appointment and document that it was made Communicate the appointment information and provide key clinical information to patient Thus far, twelve best practices have been identified among the three pilot hospitals in Phase 1, summarized below. Detail on each of these practices is included in the subsequent pages. 1. Segment the population to understand what s driving the themes you re seeing and stratify patients when initiating an intervention: There may be challenges that only affect some groups. If your hospital does not have capacity to make appointments for all patients in the ED, consider targeting one segment of the population first. 2. Select target areas for improvement based on where you are most likely to move the needle now. Success during Phase 1 is more likely if the site can determine where it is possible to make an impact with existing resources, and to focus energy there first. 3. Be incremental in your approach: In addition to mapping a target state workflow, one hospital opted to also map and implement an intermediate state work flow that improved upon some of the gaps noted while awaiting additional resources necessary to achieve the true target state workflow. 4. Start with the right location and time of day. Pick one ED (either adult or pediatrics) and one tour or shift to pilot improvement work. 5. Whenever possible, the patient should leave with their appointment in hand. 6. Consider utilizing guidelines for timing of follow up appointments (tiered urgency). Only patients for whom a primary care appointment is clinically necessary should be scheduled for one. Guidance is provided on specific diagnoses requiring follow up within a maximum of 14 days, included in the detailed best practices within this document. 7. Get to know your community PCPs to understand the best way to collaborate 8. Proactively reach out to patients known to have a high no show rate. Work closely with ambulatory care clinics to contact patients by phone in advance of primary care appointments to improve the hand off, with the goal of increased actual attendance. 9. Hold weekly team meetings for ED schedulers and workgroup members to share and track progress, successes, and challenges 10. Success will require collaboration across multiple groups of stakeholders: Ambulatory care leadership and Information technical are critical to success. The ED workgroup should have diverse representation as well. 11. If there is currently no method to track something you think is necessary, create it. If you

think something could be measured relatively easily, engage in the necessary conversations with your team to explore a simple method to capture that data. 12. Educating Users on Changes Made is as Important as Making them. Any strategy for improvement is only successful if users adopt it, so think carefully about ongoing staff education and dissemination of new practices to promote sustainability. PROJECT OVERVIEW PROJECT OBJECTIVE The objectives of the ED Care Triage project, as reflected in State defined metrics, are to: Reduce hospitalizations and ED visits, Increase primary care linkage; and Support care coordination. PROJECT DESCRIPTION The ED Care Triage project aims to improve the care of patients who are treated and released from the ED. Patients may have a variety of needs upon discharge from the ED, ranging from a large proportion of patients who require primary care follow up appointments, to a smaller group of high risk patients who need care management (CM) services. To reflect this variety of needs, the ED Care Triage project is comprised of two different, but related, subprojects: Project 1: Primary Care Linkage Goal: To obtain primary care appointments for ED patients at a clinically appropriate time interval, for all patients who require primary care follow up. Project 2: ED Care Management (EDCM) Goal: To reduce hospitalizations and ED revisits by providing targeted, short term care management (CM) services for ED patients at risk of unsuccessful transitions to communitybased care. The ED Care Triage project includes the Adult and Pediatric EDs. Facilities will need to decide whether to carry out work separately or in close collaboration across these settings. Where workflows differ, facilities may find it most practical to create separate workgroups for each of these three settings. Facilities may decide to focus initial implementation on these settings and subsequently expand. PRIMARY CARE LINKAGE WORK

Hospital facilities were asked to conduct a thorough baseline assessment of primary care linkage activities according to a Five Competency Framework developed by OneCity Health, identify areas for improvement, identify systems based obstacles or resource gaps, and implement a plan for process improvement. FIVE COMPETENCY FRAMEWORK FOR ASSESSMENT OF PRIMARY CARE LINKAGE 1. Correctly identify the patient s primary care provider (PCP) 2. Determine at what time interval the appointment should be made 3. Communicate the correct provider and time interval to the scheduler 4. Schedule the appointment and document that it was made 5. Communicate the appointment information and provide key clinical information to patient KEY CONSIDERATIONS FOR ASSESSING PRIMARY CARE LINKAGE The following key considerations were given as a guide Continuity: Whenever possible, appointments should be made with the continuity practice. A patient may be more likely to attend their appointment if it is with a doctor they know and trust. Patient Preference: The patient s preference should be an important factor in scheduling and assigning their physician. While the physician assigned to a patient according to their Managed Care plan is a good place to start, it might not be the doctor who the patient would prefer to see, and be most likely to keep an appointment with. Flow of Communication: How is the appointment information communicated to the scheduler? Is the workflow for scheduling carried out as it is documented on paper, or are there places where it breaks down? BEST PRACTICES The following section of this document detail best practices learned during the pilot of Phase 1 of the ED Care Triage project Segment the population to understand what s driving the themes you re seeing and stratify patients when initiating an intervention: Thoroughly understanding the current state of primary care linkage will enable your site to identify strengths and gaps, and begin to understand where improvement can be made. Follow the guiding questions in the baseline assessment provided in the implementation toolkit. It is important for sites to understand how these workflows differ for different group of patients: those with primary care in the same facility those with primary care in another facility in the PPS

those with primary care in the community And those who are not connected to primary care at all. It is also important to understand how workflows differ on different shifts or tours, and in different EDs (Peds vs. adult). Additionally, some EDs already may have some existing care management resources that see a percentage of high risk patients. In some hospitals, only patients with care management were linked to primary care and others were not. Understanding these differences at baseline is critical to designing an effective intervention. If your hospital does not have the staffing resources to make follow up primary care appointments for all patients in the ED, consider stratifying patients and first targeting a segment of the population. It is recommended to focus efforts on ESI 4s and 5s on the ED Severity Index. These are the patients visiting the ED who do not have a life threatening emergency or a high risk situation; many of these ED visits are therefore avoidable, and related to lack of access to a PCP or insurance issues, and could be prevented if a patient is connected to primary care. Additionally, some hospitals mentioned that different demographic groups of patients may have different preferences regarding appointment scheduling. Younger, working adults with young children may have less flexibility in their schedules, and may have a higher likelihood of attending their appointment if they schedule it individually. Select target areas for improvement based on where you are most likely to move the needle now Some hospitals will identify many gaps when completing the baseline assessment. Success is most likely in Phase 1 if the site can determine where they are most likely to have impact with resources they have now, and to focus energy there. Some examples are: new and improved workflows, better methods of documentation, and improved communication. New staffing resources will be provided to sites in later phases of the ED Care Triage Project. Be incremental in your approach In addition to mapping a target state workflow, one hospital opted to also map and implement an intermediate state work flow that improved upon many of the gaps noted while awaiting additional resources necessary to achieve the true target state workflow. Start with the right location and time of day. It might be too large an undertaking to implement changes across all shifts and all days of the week at once. Pick one ED (either adult or Peds) and one tour or shift to start. It might be easier to begin weekdays 9 5 because more staff members are present, but there may be more gaps and more opportunities to improve on a night or weekend shift. Reviewing data and seeing where there is the greatest need can also help to make this decision.

Whenever possible, the patient should leave with their appointment in hand Once the patient walks out the door of the ED, it is often difficult to get in contact with them. Some sites had schedulers call the patient the next day with an ED appointment if a scheduler was not available when the patient was leaving the ED, and while this practice is better than not scheduling appointments at all, many patients were never able to be reached. Whenever possible, scheduling of primary care appointments should be done before the patient leaves. Consider utilizing guidelines for timing of follow up appointments (tiered urgency) Some sites currently have a practice of scheduling primary care appointments for all patients who visit the ED. This practice is detrimental to overall access in the facility clinics it results in a higher no show rate and lack of availability of appointments in a short time frame for patients who truly need them. Only patients for whom a primary care appointment is clinically necessary should be scheduled for one. Others patients may need a specialist appointment, and others may not need an appointment at all (though they should know who their primary care doctor is). Some patients may already have a primary care appointment scheduled in a timeframe that meets their needs, and it is important for whoever is assessing primary care linkage to ask about all of these possibilities. The guidelines below were developed based on existing work on this topic and guidance from subject matter experts at Lincoln and Bellevue. All patients discharged from the ED with the diagnoses below should be scheduled for a follow up appointment within a maximum of 14 days. If a shorter timeframe is determined to be clinically necessary by the physician, it should be indicated for the scheduler. The following list draws upon prior work from the Bellevue and Lincoln Emergency Departments. This list only includes diagnoses that specifically require primary care follow up (not follow up in other ambulatory care clinics). In the future, we may consider defining primary care more inclusively, and expanding it to include other clinic codes, such as geriatrics and women's health. We are currently working to operationalize these conditions below through ICD10 codes. Abnormal Labs or Radiology Asthma/COPD (patient hasn't been to Pulm Clinic) Chest Pain with DM/HTN CHF Treated and released DM, poorly controlled HTN>160/100

Lower Respiratory infection Pyelonephritis DVT Get to know your community PCPs to understand the best way to collaborate. Through Phase 1 work, as expected, we learned that facilities found it most difficult to schedule appointments for patients who receive primary care in the community. For a busy scheduler, there is often insufficient time to look up the contact information of community physicians. While it will never be possible to collect contact information for all, most facilities were able to name a few PCP practices where a sizeable percentage of their patients got primary care. By collecting and posting the phone numbers even just for the top five practices in your ED where schedulers on any shift can see, a site can be make a big impact. One pilot hospital held a collaborative session with a number of Community PCPs to understand their preferences for communication and collaboration around shared patients and learned that while some practices may appreciate EDs scheduling follow up appointments for their patients, many PCPs prefer receiving notification that the patient was in the ED, along with the discharge summary, but scheduling the patient directly through their own office staff. Proactively reach out to patients known to have a high no show rate Some clinics will be able to generate a list of patients with a high no show rate (sometimes called DNKA Do Not Keep Appointments). By proactively reaching out to these patients with frequent and targeted contacts in advance of a scheduled appointment, hospitals have been working to decrease the no show rate. Getting these patients into primary care makes it less likely that they will misuse the ED the next time they need a prescription refill, or for another matter that can be handled in primary care. Hold weekly team meetings for schedulers and workgroup members to track progress In order to measure success, identify roadblocks, and problem solve, at least in the beginning, it is important to have frequent, structured check ins. Pilot hospitals held weekly team meetings to review data including number of primary care appointments requested, and any access issues noted and found these to be very worthwhile Success will require collaboration across multiple groups of stakeholders All hospitals in the pilot phase were successful by working very closely with Ambulatory Care Leadership. Some hospitals emphasized the importance of engaging the IT department early, emphasizing the crucial role IT plays in successful primary care linkage activities. The ED workgroup should also draw from a diverse group of both administrative and clinical

backgrounds physicians, nursing, care managers, pharmacists and other groups as needed. If there is currently no method to track something you think is necessary, create it! One of the most likely struggles your workgroup will come up against is lack of data. If there s something that s currently not captured or measured that you think should be, engage in the necessary conversations to explore a solution or a workaround. For example, one hospital learned during the baseline assessment that there was currently no method to identify, track and monitor ED follow up appointments made for Pediatrics patients. The facility lead worked to problem solve by engaging the right stakeholder. Together with the Pediatrics Clinic Administrator, a new ED follow up indicator in Soarian (scheduling system) was developed. This field is reportable, and was able to provide the site with the information needed to track and monitor program success. Educating users on changes made is as important as making them All of the strategies mentioned above are only successful if the users adopt them. Early engagement, training, monitoring adoption, and retraining will be necessary and should be planned for. For example, in the above example, staff in services were held to disseminate information on new Soarian codes used to schedule primary care appointments scheduled in the ED, but the work did not end there. The workgroup then monitored the use of these codes over time to determine whether retraining was needed As more sites begin this meaningful work, we look forward to learning from their efforts and sharing additional best practices.