One health network's solution to reducing non-emergency cases in the emergency department requires a change in culture-for patients and physicians.

Like so many hospitals around the country, Presbyterian Hospital in Albuquerque, N.M., is facing a costly problem: Payers no longer want to pay emergency department (ED) prices for non-emergency care.

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In July, the 453-bed hospital started a program aimed at reducing ED traffic by deferring such non-emergency cases like earaches and minor wounds to the hospital's primary care physicians. Currently, the hospital's ED gets about 180 visits a day; the goal is to reduce the number of ED visits by 10 to 15 percent, says Mark Stern, MD, medical director, Medical Management and Endcare Coordination, Presbyterian Healthcare Services, a network of eight hospitals in New Mexico.

Lisa Farrell, CFO for Presbyterian Health Plan, the network's integrated insurance plan, says the program should see savings beginning in 2011 amounting to $10 million to $15 million over the course of five years.

Called the "ER Navigator Program," the project has customer service representatives in the ED to set up appointments with the system's primary care physicians for non-emergency patients. All patients are first triaged by a nurse to determine the required level of care. Cases like earaches, sore throats, and lower-acuity upper respiratory infections in patients older than two years old are sent to a clinician, such as a nurse practitioner, who performs a screening and obtains a medical history. Cases that are non-emergent or non-urgent are sent to customer service representatives, called navigators, who then schedule an appointment for the patient to see a primary care physician within 12 to 24 hours; uninsured patients are connected to other care resources within the community.

ED No Longer a Safety Net

Slightly less than a month after its launch, the program had deferred about 60 ED patients to navigators, below the 18 to 24 ED patients per day hospital administrators had hoped to divert to primary care physicians, Stern says. He expects the number of deferred patients to increase as clinicians become more attuned to the parameters of the program.

One of the challenges in setting up the program was gaining buy-in from ED physicians, who were concerned that deferred patients wouldn't receive care, Stern says. However, because patients are given appointment to meet with primary care physicians, not just referred to these physicians, ED physicians have become more accepting of the program, he says. "What we're doing at Presbyterian is shifting paradigms from the emergency department being a safety net to a well-integrated system being a safety net," he says.

Stern says administrators will continue to refine the program as they meet with ED and primary care physicians to get updates and feedback on whether the program is working the way it was intended. Physicians will receive data on the number of patients who have been set up with care appointments, but who don't follow through with the visit, he says.

Program Costly at First

Reducing costs in the ED is part of Presbyterian Healthcare Service's systemwide medical cost optimization program, which was initiated in late 2009.

The goal of the program is to help patients access care in a setting that is more appropriate for their medical condition. "By treating patients with non-emergencies in a more appropriate venue than a high-cost acute care setting, we help to reduce healthcare costs overall for everyone," Farrell says.

However, Stern says the program is expected to cost money before it saves money. In many cases, the primary care visits set up by the navigators are not reimbursed. "This is probably something like a nine-month to two-year project" to change the behavior of patients and ED staff and to help patients understand the proper venue of care for non-emergency cases, he says.

Although physician buy-in was the priority, Farrell says administrators also made sure to seek support from federal regulators and advocacy groups, like Albuquerque Healthcare for the Homeless, before launching the program. The health network also implemented a comprehensive communications initiative with the community by giving media interviews, making public service announcements, and sending letters to previous ED patients, health plans, and their members explaining the program. "We really tried to make people aware of the program and what we're doing," she says.

Farrell adds that the health network has received no complaints about the program from regulatory agencies, and patients are accepting of the program as well. About one month into the program, just one patient left the ED angry about the deferral, Stern says. But the patient later came back to apologize-and make an appointment with a primary care physician.

"I think we're getting the results we anticipated," Stern says.

Publication Date: Tuesday, October 12, 2010