Providing care in the right settings helps hospitals improve care and reduce costs.
To better understand the children who frequently use the emergency department (ED) and the health services they receive during those visits, a Children's Hospital Association-facilitated research group examined 2011 to 2012 data from 40-plus hospitals participating in CHA's Pediatric Health Information System (PHIS).
In the study, the group identified children who visited the ED and tracked them over a year to see how many times they returned to that ED. They found many children with four or more ED visits actually needed few health care resources.
Updating the study with 2014 to 2015 PHIS data, the percentage of children who visited the ED four or more times was 6 percent representing 19 percent of visits and 25 percent of costs. To ensure patients are receiving care in the most appropriate setting, here are some effective children's hospital practices:
Invest in underserved areas in the community
Guided by data, Texas Children's Hospital expanded its services to allow for more appropriate use of its ED. Analysis of ED visits showed a high number of patients with non-emergency needs because of inconsistent medical resources available in the community. To help with this, Texas Children's targeted underserved geographic areas for community based primary care centers, which would serve as medical homes for families.
Texas Children's opened its first community center in 2000. Today, there are six centers within a 10-mile radius of the hospital's main campus serving approximately 30,000 children. Also, two centers for women and children, owned by Texas Children's Health Plan, provide care for nearly 18,000 children and 3,000 pregnant women. Each center serves as a patient-family centered medical home, including extended hours and some urgent care services.
"Over the last few years, we invested in community care," says Angelo Giardino, M.D., senior vice president, chief quality officer. "We specifically looked for sites where our data showed families had few, if any, options for a medical home. Providers working in these settings are meeting a primary care need that should offset the default to seeking emergency care."
The organization's other strategies for reducing emergency visits include opening urgent care centers (UCC) throughout the community. There are currently six sites with four additional sites planned for 2017. One of the sites is adjacent to the ED at the hospital's main campus. Here, patients can self-select a UCC visit, or providers screen them in the ED and offer a UCC visit if the patient meets criteria. This patient-centered model allows for a faster and lower-cost visit.
Since implementing this strategy, the ED has seen a decrease in its low acuity visits, from as high as 45 percent from 2013 to 2015, to just 20 percent in 2016. "Providers see about 25 percent of patients arriving at the main campus in the UCC—17 percent in the ED and 8 percent self-select the UCC," says Binita Patel, M.D., chief of quality, Pediatric Emergency Medicine. "Only 2 percent of those kids are sent back to the ED, reflecting a good screening process."
Enlist the help of ED case managers
Four years ago, the ED providers at Children's Hospital Colorado were struggling with the ED versus observation determination for patients, so the organization hired an ED case manager. The case manager serves as a referral resource for families who needed assistance getting established with primary care, filling medications and making appointments for sub-specialty services.
"Frequent ED utilizers for low acuity issues were one of the biggest challenges and led to staff dissatisfaction," says Jann Hodge, B.S.N., RN-MBA, CCM. "We were seeing the same kids over and over for complaints such as fever, diaper rash, cough or upper respiratory infection, ears and fussiness."
In 2016, as part of Hodge's participation in a week-long long symposium by the Center for Trans-disciplinary Evidenced Based Practice, she conducted a literature review on pediatric ED overutilization. A study of more than 13,000 Medicaid children ages 0 to 20 years from a single accountable care organization in Minnesota found that past ED utilization was not a predictor of future use except for children less than 1 year old.
The findings suggested that case management interventions focused on young mothers with infants would be most effective in reducing low acuity ED visits and associated costs. "When we look at the CHA analysis on ED utilization at Children's Hospital Colorado, it reflects the findings from the Minnesota study, particularly when it comes to ED utilization for children less than 1 year of age," Hodge says.
The hospital team plans to create a system to identify young mothers with infants for referral to case management. The organization will also expand ED screening for social determinants of health beyond a small subset of asthma patients. In addition, the hospital's Young Mothers Clinic staff will review its parent education materials to determine what can be used in the ED.
Further case management interventions will be driven from what is learned through family outreach and the social screener. "When I started in this position, I naïvely believed getting kids established with primary care and reducing ED visits would be simple. What I've learned in working with our families is they face obstacles to accessing primary and sub-specialty care, and for some families, navigating our complex health care system without assistance is nearly impossible," she says.
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