Private Benefit Networks

Emergency Department Diversion

Despite ongoing efforts, Emergency Department (ED) use for non-emergent visits continues to rise, placing significant ongoing cost pressure on community resources, hospital providers and payers. ED use is the most expensive option for meeting non-emergent issues, with average non-emergent ED costs charged at approximately $1,220 per visit. The same intervention in a location-appropriate setting costs approximately $125. It is estimated that 15% - 20% of all ED visits are for non-urgent or primary care treatable issues. Medicaid beneficiaries are much more likely to use ED's in these situations across all age groups. Further, ED's have become the main source of non-elective hospital admissions (up to 70% in some demographics).

Numerous attempts have been made to stem this tide, many with questionable results. Key challenges include:

• Primary Care provider access


• Community and population education


• Demographic data - who is utilizing, utilization times, etc.


• Diagnosis data - discharge diagnosis as non-emergent, correlation between complaint and condition


• Use of multiple ED locations


• Poor communication between ED and actual/potential providers


• Failure to recognize and accommodate social determinants


• Strategies for both pre-visit diversion, as well as on-site diversion, to condition appropriate setting


• Integration of required specialist intervention

To meet these needs in a cost-effective manner, existing resources must be integrated through a central hub and spoke collaboration

Key Determinants

• Avoidance of ED visit, if possible, to reduce the need for on-site response


• On-site diversion capability to deal with the substantial cohort, which continues to utilize the ED location based on cultural bias, availability of support services (labs, RX and imaging) and other social determinants


• Identification of non-emergent situations in real time, and upon discharge


• Effective follow up and engagement, via Patient Home capabilities


• Full adherence to EMTALA implications

General Process - A successful ED diversion strategy must recognize and integrate community-based education, pre-visit outreach, on-site diversion strategies, common EHR data and treatment follow-up.

Pre-Visit

• Public Health and community outreach, including education and incentives to attend best location


• Identification of 'Frequent Flyers', as well as other ongoing non-emergent users and comorbidity patients


• Establishment of a general 'Gatepper' process (potentially on a capitated basis)


• Payer sponsored patient financial information

Hospital Visit

• On-site Nurse Practitioner triage desk, in conjunction with traditional ED intake


• On-site open scheduling technology


• On-site or close-proximity clinic location (Diversion Center)


• Diversion Center must provide extended hours to respond to critical utilization times


• Transportation/Shuttle bus service provided for close-proximity clinic locations


• Strategy for obtaining lab and imaging needs when using close-proximity clinic location


• 24/7 off hour coverage, including telehealth support, which is widely communicated and accessible

Combined Functionality

• Whether pre-visit or on-site diversion, Intensive Case Management is required
  
  • Individualized Care Plan and RX adherence program must be established for participants
  
  
• Program must undertake an assertive community outreach position, incorporating collaboration among:
  
  • Public Health resources
  
  
  • Existing providers
  
  
  • Other community-based services
  
  
  • Community health centers
  
  
  • Government payers
  
  
  • Private practice physicians
  
  
• Integration of specialty services, including:
  
  
  • Behavioral health
  
  
  • Infectious disease
  
  
  • Substance abuse
  
  
• Strategic plan for dealing with complex cases and significant comorbidities


• Daily hospital updates to ED Diversion plan coordinator and existing providers, if possible, regarding inappropriate utilization, follow up strategies and referrals recommendations

Methodology

• Hub and spoke coordination must be established among all collaborating partners
  
  • Existing FQHCs
  
  
  • Coordinating FQHC
  
  
  • Participating Hospital
  
  
  • Other hospital EDs in region
  
  
• Effectively exchange health data (EHR and other) among all partners, in real time


• Program coordinator as part of triage process


• On-site, real time scheduling for referrals and follow up


• Establishment of Care Plan for all participants


• Integration of Behavioral Health


• Strict substance abuse policy


• Mandatory monitoring of prescription RX utilization and integration of RX adherence with Care Plan

Summary

Many of these required capabilities already exist in the community in various forms. Often, the challenge is not one of resources, but rather the effective coordination of services, coupled with expanded data sharing. Establishment of an FQHC-based, hub and spoke collaborative structure is critical to a successful ED Diversion strategy. This offers the opportunity to include existing private-pay providers and other hospital settings, creating a visual, clinically integrated network (CIN) structure for ED use. Further, such a collaborative strategy provides the opportunity to establish an appropriate value reimbursement strategy for all affected payers in the footprint.

The hub and spoke collaborative can also be integrated with hospital sponsored, discharge management initiatives (mitigating re-admission challenges), as well as in the establishment of broader, Population Health Initiatives, all under the same strategic infrastructure.

Target Population

1. Public sector health plans
2. Hospital Emergency Departments
3. At risk patients with inadequate access to primary care.
4. Medicare populations

Back to PBNs

For more information contact us at info@strategic-healthsolutions.com