Findings Could Deliver Better Care, Reduced Costs, Shorter Waits

PRINCETON – As the use of hospital emergency departments grows across New Jersey, a new project from the New Jersey Hospital Association examines the problem of individuals using the ED for non-emergency care. More than one-third of ED use is for non-emergency primary care conditions that could be treated more appropriately – and more affordably – in a doctor’s office or clinic.

In New Jersey alone, ED use has increased 27 percent between 2000 and 2010. And more than $400 million a year is spent on avoidable ED visits, according to the National Association of Community Health Centers.

Community Partnership for ED Express Care and Case Management, a two-and-a-half-year demonstration project led by NJHA’s Health Research and Educational Trust, the state Department of Human Services and the New Jersey Primary Care Association, took a microscope to the issue of non-emergency cases turning up in the state’s EDs. Supported by a $4.8 million grant from the federal Centers for Medicare and Medicaid Services, the project closely followed utilization of two hospital emergency departments and tested interventions to help patients receive primary care services in a more appropriate and less expensive setting.

Key conclusions from the initiative include: The capacity and accessibility of the state’s primary care system – particularly for Medicaid patients – are insufficient; primary care solutions are needed especially for behavioral health and mental health patients; and relationships among healthcare providers are key to improving care coordination and patient education.

“This project is all about patients – making sure they get the right care in the right setting,” said NJHA President and CEO Betsy Ryan. “But this is one of those scenarios in which doing the right thing for the patient also can produce savings in healthcare costs. It’s a win-win.”

Newark Beth Israel Medical Center and Monmouth Medical Center served as the pilot sites, in tandem with their respective local health centers, the Newark Community Health Center and the Monmouth Family Health Center. Implemented from September 2008 through April 2011, the project tested a model for providing alternate non-emergency services to patients who presented to the ED with non-urgent primary care needs. The model used an “express care process,” in which patients who came to the ED with a non-emergency situation were assessed by a clinician and provided the appropriate services. But then the ED staff took extra steps to refer the patient for a follow-up visit with a primary care provider, or if the patient had no regular physician, immediately scheduled an appointment at the partnering federally qualified health center. The ED staff also educated the patient on the appropriate site of care for various healthcare needs and the importance of having a “medical home” for primary care needs.

In addition, case managers stationed at both the hospital ED and health centers coordinated services and arranged transportation and support services. The sites also identified repeat ED users, tracked compliance with follow-up care and assisted with referrals for specialty care. Through it all, the initiative stressed communication between the hospitals and health centers, supported by mutual electronic systems that could schedule appointments and coordinate care.

"The NJPCA considers this to be one of the most timely projects that we have been involved in,” said President and CEO Kathy Grant Davis. “This was all about making sure that patients have a medical home in a primary care setting and that hospital emergency rooms are not being used to serve this purpose. The federally qualified health centers in New Jersey will now continue the best practices learned during this project. Patients will be given educational information that helps them determine when to use the emergency room and when to use their primary care provider. The goal is to reduce overall health care costs by utilizing settings that are proven to be less costly."

Key Findings

The project and its interventions yielded progress toward the goal of promoting medical homes and appropriate sites of care and in reducing the use of hospital EDs for non-emergency conditions. Specific findings provided the following information on the non-emergency users of hospital EDs:

• The two pilot EDs tracked more than 10,000 visits over a two-year period for situations that were not emergencies, out of approximately 52,000 total non-urgent visits. All told, the two EDs cared for roughly 195,000 ED cases in that period. 
• The peak day for primary care visits was Monday, and the peak times for such visits were 10 a.m. to 1 p.m. That information runs counter to the prevailing belief that most non-emergency cases came to the ED during hours that the federally qualified health centers were closed.
• 89 percent of the non-emergency ED patients were uninsured or covered by Medicaid.
• Insurance status predicted the frequency of repeat ED use, with 54 percent of those returning for four or more visits covered by Medicaid or NJ FamilyCare HMOs, compared with 19 percent uninsured.
• Non-emergency patients gave the following survey responses for the reasons they used the ED: 21 percent felt they needed emergency care, 20 percent said their doctor’s office was not open and 12 percent said their doctor was not available that day.

The final report also revealed the following results from the project’s interventions:

• At the project’s conclusion, ED visits for primary care needs had declined 22 percent at a time when overall ED visits increased by about 1 percent. Inappropriate utilization decreased 47 percent among Medicaid patients in particular.
• There was a 19 percent increase in patient volume at the community health centers, including a 30 percent increase for Medicaid patients.
• Reduced ED utilization for primary care needs helped improve patient flow throughout the ED, cutting patient turnaround time by an average of 15 percent.

Recommendations

The report offers several recommendations for taking advantage of this model in the future:

• Consumer outreach is needed to educate the general public about the importance of using EDs only for true emergencies.
• Federally qualified health centers must promote their services competitively, making the availability and quality of their services known to all populations. 
• Medicaid HMOs must increase their involvement and the network of primary care providers.
• Policy changes are needed to create economic incentives for patients to use primary care sites. Poor and low-income patients are more inclined to go to EDs, where care is effectively “free,” rather than pay the sliding-scale fees at the federally qualified health centers.
• Connectivity between hospital EDs and community primary care providers is essential.
• This study was unable to demonstrate total cost savings due to inadequate cost data from the community health centers. Future pilots should incorporate a more comprehensive cost impact analysis.

The project and its findings provide valuable information to help improve care coordination for New Jersey patients and ultimately achieve the goals of healthcare reform: improved care at reduced costs.

“The Department of Human Services has made great strides developing ED alternatives,” said DHS Commissioner Jennifer Velez, whose department serves individuals with low incomes, disabilities and behavioral health needs. “As the state advances medical home and accountable care organization pilot programs, an administrative services organization (ASO) for behavioral health and payment reform, I’m confident we’ll see improved coordination of care that effectively changes patient behavior and reduces unnecessary ED visits.”