Managing Care and ED Utilization

Sept. 29, 2011
Indeed, says the report, between now and 2015, the year after some of the most important health insurance reforms are scheduled to take effect, the shortage of doctors across all specialties will quadruple. The association says its previous estimate of a nationwide shortage of 39,600 physicians will more likely approach a shortage of 63,000, with a shortage of 33,100 physicians in such specialties as cardiology, oncology, and emergency medicine.

Over the past few years, the physicians at Hillside Avenue Family and Community Medicine, a six-doctor family medicine group in Pawtucket, R.I., with an active patient base of 15,000, have been able to develop a patient-centric medical home model, moving forward with the support of a state-level grant to implement such a model, through a program called the Rhode Island Chronic Care Sustainability Initiative. Hillside Avenue was one of five medical groups given that grant; the five physician organizations have been working collaboratively with all the major health insurers in the state on issues such as reducing readmissions to emergency departments and hospitals.

The work of tracking patient status and managing patients’ disease states and care has led to Hillside Avenue’s receiving the 2010 McKesson Distinguished Achievement Award from the Alpharetta, Ga.-based McKesson Corporation, Hillside Avenue’s vendor partner (the Hillside Avenue physicians use McKesson’s Practice Partner electronic health record (EHR) solution to support their care management work. McKesson selected Hillside Avenue’s physicians for the award partly in recognition of a group of achievements they’ve made to date, including reducing their patients’ emergency department (ED) usage by more than 10 percent over the past year; reducing average blood glucose levels among their diabetic patients by 5 percent; screening more than 50 percent of their adult patients for depression; and providing formal smoking cessation to more than 75 percent of their adult patients who smoke.

HCI Editor-in-Chief Mark Hagland spoke recently with Kenneth Sperber, M.D., physician operating officer at Hillside Avenue Family and Community Medicine, regarding his organization’s work in the patient-centered medical home arena.

Healthcare Informatics: What compelled you forward to begin this initiative?

Kenneth Sperber, M.D.: We’re involved in the Rhode Island Chronic Care Sustainability Initiative, CCSI Rhode Island. The state put it together about two years ago. It started out with five practices and all the major payers in the state, along with the Rhode Island Office of the Health Insurance Commissioner, called OHIC, which oversees the health insurance industry here in Rhode Island.

The role of OHIC in this is that it was necessary for OHIC to be involved in order to create a waiver for a demonstration project around the patient-centered medical home; otherwise, it would have constituted an antitrust violation for the five practices and five payers to sit down and talk together about payment and care management.

HCI: When did OHIC convene the five groups and five insurers?

Sperber: About three years ago. And it took about a year to hammer out what the plans would pay to start those projects, and for a practice to implement EMR adoption, as part of this. One of the practices among the five didn’t even have an EMR at all; most of the others had one, at various stages. We’ve had an EMR since 1992, and have been paperless since 1994.

We weren’t yet doing all the things required to become a certified patient-centered medical home under NCQA [the Washington, D.C.-based National Committee for Quality Assurance]. We now have a nurse case manager to help follow up with patients on things like eating plans.

Patient-centered medical homes are where we think the future of healthcare is going. So we began two years ago. And the project has now expanded beyond in the initial five sites, and now we have nine or ten. NCQA has three levels of certification, with different standards, level three being the most advanced. The initial five sites are now level one certified patient-centered medical homes. We got certified about a year ago. We were all expected to be certified as level one, and we all got that, and we’re working towards level three.

And one piece of this initiative was to try to begin to address ER utilization. And I came into the practice in 2003, and even then, one of the catch-phrases of our practice was, ‘sick today, seen today.’

HCI: Tell me more about your work averting emergency room visits.

Sperber: ER utilization reduction is going to become a much more significant part of this, by contract, in our next contract. That’s where the money is, and where the improved outcomes are. So we’re looking at everybody. We have expanded our hours, to 9 to 7 every day, 9 to 5 Friday; and we come in on Saturdays and Sundays on request. Because otherwise, large numbers of those people will wind up in ERs or urgent care centers.

And this is where the IT begins to come in. A recent version of the Practice Partner product included a new module called Clinical Elements, which is sort of a user-defined spreadsheet database that allows us to set up any number of flow charts. We have one I set up called “ER Visits,” with about a dozen different data fields, that I or a nurse complete every time a patient ends up in the ER. One trick is finding out right away that an ER visit has occurred. And we have good communication now, automated, with two of the biggest ERs in the area. So if we have a patient who hits that ER, we get an automated fax right away in our office, and we follow that up through either our nurse care manager or quality assistant, who runs disease management reports.

So, for example, maybe we had 20 patients who went to the ER last month, because they didn’t know we had a same-day policy. We’re tracking day of the week, time of day, type of insurance. And there are trends, because some health plans in the state charge no co-pays for their members to go to the ER, while some have high co-pays. So, did the patient know our office hours, or not? And did they try to call us? And how did it go? Did we fail to offer them a same-day appointment? Did they actually get referred by a doctor? Did we tell them to go to the ER, if they had chest pains, for example?

So we’re creating that database of information on every ER visit we find out about. What we’re doing is viewing all of these ER visits as failures, assuming that they’re almost all preventable events; some are appropriate, and that’s fine. But by collecting this data and tracking it, we’re expecting and hoping that we can prevent some ER visits. We’ve been doing this about a year now.

HCI: What have you learned so far from the tracking work?

Sperber: We believe that by and large, most of these visits are preventable. Many people don’t realize we’re available on the weekends, for example. We think all of our patients know that, but some don’t. A large contributor—our population of patients on this state insurance plan does not have any co-pay to go to the ER; that’s hard for them to combat. Certainly, our same-day appointment policy reduces ER utilization.

HCI: Medically speaking, are there any areas that you’re feeling the need to change?

Sperber: We’re certainly doing a lot of chronic disease management. Coronary artery disease patients on beta blockers and preventive aspirin; diabetics should maintain their hemoglobin A1c levels under 7; and we’re screening all adult patients over 18 for depression once a year; that’s one of the benchmarks of the CCSI pilot, and one of the hallmarks of a patient-centered medical home.

HCI: Tell me about the benefits of having this linked to your EMR and being fully automated?

Sperber: Medicine, almost more than anything else, is information management: the better we manage the large body of data and information that each patient represents, the better we’re able to really respond to that database of information. So we have this resource that can cross-pollinate itself, so I can bring patients’ current medications into their progress notes at the touch of a button; I can bring the fact that I gave them their flu shot into the database at the touch of a button; and having all this information pop up inside decision support tools, has exponential value. Computers manage data a lot better than manila folders do.

HCI: What are the lessons learned that you can share with physicians in other practices?

Sperber: One thing that’s really important is the organization piece of this. This is not one practice trying to do all these things in isolation. Family medicine/primary care is just not reimbursed in a way that makes it possible for practices to invest in new initiatives in this way; so you really must organize in your region or your state to make that possible, and the payers have to say, yes, we’ll kick in a few dollars a month to make this possible. There’s expense involved in investing in infrastructure; and there’s expense involved in reimbursing the physicians for this work. And there’s often a lot of resistance on the part of payers to this. But the return on investment here is very big.

On the one hand, the health plans are saying they want ‘proof’ that this kind of program works. But that’s asking for proof of the obvious; and two years of data is not enough to prove that. It’s going to take five to 10 years to produce the measurable benefits here that everyone says they’re looking for. And that’s a challenge, to get everyone to think long-term, because that’s not what has been historically the thought patterns. In the case of this program, the health plans are putting in $3 per member per month. That’s not a lot. And yet the return on investment is huge.

HCI: What are the IT requirements for helping to build and sustain this kind of program?

Sperber: You need an EMR that is customizable. We have that. And I created this ER visit/clinical elements spreadsheet, and now if I go into Practice Partner’s patient inquiry module, I can have it run a report about which patients have [gone to the ER on] Wednesday, in this spreadsheet. It’s capable of doing a search for things that I added to my Practice Partner. And that’s important: you want a product where the vendor is capable of reporting on elements that aren’t in the product.

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