Emergency Department Mitigation Best Practices
Attempts to mitigate unnecessary emergencydepartment use are myriad and have had varied degrees of success. Nationally, several measures have been identified as best practices which over time have contributed positively by improving patient access and awareness as well as diminishing gaps in communication between different points of care. For ease of reference, these have been subdivided based on provider initiatives, patient population and diagnosis. Click on the links below for best practices identified nationally.
Provider Navigation, Management, and Coaching of Patients
Community Referral Liaisons Help Patients Reduce Risky Health Behaviors, Leading to Improvements in Health Status
Community Health Educator Referral Liaisons (CHERLs) helped patients reduce drinking, smoking, and physical inactivity by linking them with community resources, offering counseling and encouragement over the telephone, and providing feedback to referring physicians [AHRQ-supported project].
Chronic Care and Disease Management Improves Health, Reduces Costs for Patients With Multiple Chronic Conditions in an Integrated Health System
Combining chronic care and disease management for patients with multiple conditions reduced hospitalizations and visits to specialists and the ED. Capitation payments allowed for shared savings among the payer and providers.
Donaldson N, Rutledge D, Geiser K. Role of the external coach in advancing research translation in hospital-based performance improvement. Advances in patient safety: new directions and alternative approaches. Vol. 2, Culture and redesign. Rockville, M.D. Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0034-2.
This article describes implementation of an innovative telephone-based coaching intervention aimed at reducing the incidence and severity of patient falls at 33 California acute care hospitals from the pre-engagement to the closure phases. The article discusses feedback and self-assessment results from participating hospitals, as well as the impact of the intervention on fall-related policies and clinician practices.
Process, Communication and Practice Improvement
Electronic Medical Record–Facilitated Care Process Redesign Enhances Access to Care, Reduces Hospitalizations and Costs for Patients With Chronic Illnesses
This initiative redesigns patient care and workflow processes for chronically ill patients to take advantage of the organization's full-function EMR and wireless tablet personal computer technologies.
Solo Physician's Use of Virtual and Phone Visits, Same-Day Appointments, and Extended In-Person Visits Leads to High Patient Satisfaction and Improved Chronic Disease Outcomes
A solo family practitioner reports how she designed her practice along the lines of the Ideal Medical Practice (L.G. Moore and J.H. Wasson). Without foundation or research support, she introduced year-round, 24-hour-a-day, 7-day-a-week access to care for her patients through liberal use of "virtual" or E-mail visits, telephone calls, same-day appointments, and extended office visits. The initiative is gratifying to the provider and has fostered patient satisfaction, low patient turnover, improved outcomes for patients with chronic disease, and lower costs.
E-Mail and Telephone Contact Replaces Most Patient Visits in Primary Care Practice, Leads to More Engaged Patients and Time Savings for Physicians
Like the preceding entry, this case reports on a redesign using virtual visits. GreenField Health is an independent clinic that has a research and development arm.
Revamped Scheduling Systems Promote Access, Reduce No-Shows, and Enhance Quality, Patient Satisfaction, and Revenues in Primary Care Practice
Using the "advanced access model" (and without external funding), a primary care practice in Rhode Island revamped its appointment scheduling, tracking, and reminder processes to enhance access to same-day appointments and achieve the results listed above.
Revised Processes Related to Daily Opening Reduce Wait Times and Enhance Patient Satisfaction at Two Urban Clinics
Urban Health Plan, a federally qualified health center for underserved communities in the South Bronx, redesigned operational processes (e.g., checklists for start and end of day; staff assignment based on anticipated demand); the two clinics also standardized and streamlined layout. These changes improved care efficiency and improved patient-provider interactions.
The University of Arizona College of Medicine, Pharmacy and Nursing, launched ER-Link in 2007. The system allows physicians in UMC's ED to triage cases remotely via video equipment installed on the city's 19 ambulances, through 20- to 30-second "snapshots" when the vehicles are stationary, and also while they're in transit. The system was made possible by a 227-square mile wireless infrastructure covering 95% of the population that the city of Tucson created with a $3 million federal grant. (Urgent Matters E-Newsletter; Volume 6, Issue 2; November/December 2009; Special Focus Issue- Patient Intake)
Patient Education and Outreach
A UnitedHealthcare diabetes health plan (tested this year with three national employers GE, Hewlett-Packard and Affinia Group) gives enrollees financial incentives to take better care of themselves. The rewards are for adhering to a schedule of routine preventive care, such as regular blood sugar checks, exams and screenings. United says the initiative can slash a diabetic employee's total health care costs, which average more than $22,000 a year. The program is available to self-insured commercial plan customers, who can tailor the benefits to their needs. Options include cash rewards for every quarter of compliance, free diabetes supplies and prescription drugs, and lower co-payments for diabetes-related doctor visits. Employees can save $500 a year. Crain's Health Pulse - 11/12/09
- Postdischarge Care Management Integrates Medical and Psychosocial Care of Low-Income Elderly Patients
This new care program improves reported health and saves $600-$1,000 per month in reduced rehospitalization expenditures. [AHRQ-supported project].
- Onsite Nurses Work With Primary Care Physicians To Manage Care Across Settings, Resulting in Improved Patient Satisfaction and Lower Utilization and Costs for Chronically Ill Seniors
This initiative improves care for chronically ill seniors; specially trained nurses work with primary care physicians to coordinate care, facilitate care transitions, and act as patient advocates. Results include improvements in reported health and savings of 23 percent on readmission costs. [AHRQ-supported project].
- "Hospital at Home" Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients
This initiative provides hospital-level care (including daily physician and nurse visits, diagnostic testing, treatment, and other support) in a patient's home as a full substitute for acute hospital care for selected conditions.
- Plan-Funded Team Coordinates Enhanced Primary Care and Support Services to At-Risk Seniors, Reducing Hospitalizations and Emergency Department Visits
Commonwealth Care Alliance of Massachusetts developed a health plan (Senior Care Options) that provides low-income, dual eligibles with a primary care team (physician, nurse practitioner, and geriatric specialist) in the enrollee's primary care clinic. The team ensures that these medically complex individuals receive needed medical care and social services at no additional cost to the enrollee. The program improved prevention, screening, and chronic disease management; reduced hospital stays, hospital admissions, and ED visits; and lowered costs and length of stay
Fidelis Care’s QCMI Program rewards group/practices for providing recommended preventive care and proving chronic disease care, maternity and mental health care. The measures that are included in the program are part of Quality Assurance Reporting Requirements (QARR) - a set of measures that the New York State Department of Health (NYSDOH) uses to assess how well health plans care for Medicaid, CHP and FHP members.
The Asthma Network of West Michigan provides intensive home-based case management services to predominantly low-income children and adults diagnosed with moderate to severe asthma. The community organization uses nurses or respiratory therapists to provide up to 18 home visits. Visits include asthma education services in the home and some environmental education.
Asthma IQ is a web-based tool to help physicians understand and apply the NIH National Asthma Education and Prevention Program asthma guidelines. The tool was designed to document and improve the quality of patient care. It is listed as a best practice by the Global Alliance Against Chronic Respiratory Diseases (GARD).
American College of Emergency Physicians recommends developing an asthma management plan with your doctor to monitor the condition and a medication plan when trouble develops. It incorporates measures to determine triggers for asthma and ways to avoid these triggers.
HHC has a corporation-wide telemedicine program called House Calls that targets 500 severe diabetics. HHC says that 76% of those enrolled for six months cut their blood sugar levels, with 22% of that total reaching a healthy sugar level. Teaching diabetics to manage their own treatment costs about $3,600 a year per patient, says HHC, far less than the cost of a single day in a hospital or emergency room. Under House Calls, patients recorded a 50% drop in unplanned doctor visits, hospitalizations and ER visits. The program is available for free to the 16,479 diabetics enrolled in MetroPlus, HHC's Medicaid plan. HHC cares for more than 50,000 diabetic patients and hopes eventually to make House Calls available to all eligible diabetics.
Learn More, Breathe Better campaign of National Heart, Lung and Blood Institute, National Institutes of Health, USA hopes to increase awareness of COPD as a serious lung disease—the 4th leading cause of death in the United States and that it is treatable. The campaign encouraged people at risk to get a simple breathing test and talk to their doctors about treatment options. The target groups were at risk men and women (smokers and former smokers aged 45+), diagnosed COPD patients and their caregivers, and health-care providers. It is listed as a best practice by the Global Alliance Against Chronic Respiratory Diseases (GARD).
Baystate Medical Center introduced a comprehensive heart failure management program which incorporates assessment of left ventricular function, use of medications according to accepted guidelines, provision of immunizations and smoking cessation counseling, and thorough discharge instructions. The program was successful in reducing heart failure readmissions from 25 percent in 2000 to between 4 and 10 percent currently.