Emergency Department Setting:

  • Trauma Center/Tertiary Care Hospital for multiple-county area
  • 54,000 annual ED visits
  • 24 ED beds

Goals:

  • Operationalize strategic goals related to evolving models of payment and care delivery, such as:
    • Accountable Care Organizations (ACOs)
    • Medical Homes
    • Quality Care
    • Cost Reductions
    • Wellness and Prevention
  • Identify high-risk patients:
    • At risk for violence toward staff
    • At risk for self-directed violence (National Patient Safety Goals)
    • At risk for dependent behaviors
  • Reduce unnecessary visits
  • Reduce complaints
  • Reduce conflict between patient and caregivers
  • Improve care

Process:

Coordinated Care Medical Action Plan (CMAP)

  • Patient identifier within HIS
  • Referrals by nursing staff, physicians, and social service
  • Visit review by Medical Director
  • Database input
  • Development of care plan by Medical Director
  • Input from primary care providers
  • Notification of patient
  • Follow-through

Criteria for Review:

  • ED patients with 4 or more visits in one month
  • ED patients with 10 or more visits in one year
  • High-risk diagnosis
  • Specific behaviors
  • Specific concern from care providers

Care Plans:

  • Generic plans modified for individual patient
  • Example: migraine
    • Treatment protocol for ED care
    • Referral to appropriate specialist or medical home
    • Call to PCP, specialist, per care plan

Benefits:

  • Superior and more effective alternative to triaging out programs
  • Cost savings – reduce unnecessary visits and diagnostics
  • Improve patient care:
    • Pain specialist referrals
    • PCP referrals
  • Decrease friction between patients and caregivers
  • Improve safety:
    • Staff
    • Patient
    • Visitors
  • Compliance – National Patient Safety Goals (NPSG)
  • Decreased time spent on patient complaints

Resources Needed:

  • Physician
    • Referrals
    • Visit review
  • Nursing
    • Referrals
    • Buy-in
  • Hospital
    • Patient identifier
    • Database
    • Case manager
    • Discharge instructions
  • Medical Staff
    • Pain management
    • Medical homes

Results:

  • Reduced complaints
  • Increased staff and physician satisfaction
  • Compliance with Joint Commission and National Patient Safety Goals
  • Brings a controlled and predictable process to high-stress patient encounters in a chaotic environment
  • Cost savings
  • Visit reduction of 65% among identified population of high ED utilizers; 80% reduction in visits among to 10 ED utilizers!

Figure 1. CMAP Process

Case-Study-4-Fig-1

 

Table 1. Frequency of ED Visits Pre- and Post-CMAP Implementation

Pre-CMAP
(Patients with >= 13 ED Visits
Post-CMAP
(Same Cohort)
Total Patients 86 86
Total Visits 1,708 596
Average Visits per Patient 19.9 6.9
Patients with Zero Visits 12
Patients with Fewer Visits 69
Patients with More Visits 5*

*During the following 12-month period, 4 patients had zero visits.