Emergency Department–Based Case Managers Throughout County Electronically Schedule Clinic Appointments for Underserved Patients, Allowing Many to Establish a Medical Home
Emergency Department–Based Case Managers Throughout County Electronically Schedule Clinic Appointments for Underserved Patients, Allowing Many to Establish a Medical Home
Through the Milwaukee Health Care Partnership (a public/private consortium), the Emergency Department Care Coordination Initiative seeks to reduce future, avoidable emergency department visits by Medicaid and uninsured patients without an ongoing source of primary care. Providers in eight county emergency departments and four federally qualified health centers use a standard process to identify and refer patients in the target population. As part of the emergency department encounter, an emergency department–based case manager provides education on appropriate emergency department use and the importance of having a primary care medical home, and then schedules an appointment at a local clinic through an electronic scheduling system. After the visit, the case manager sends relevant patient information to the clinic. The clinic's intake coordinator follows up by telephone to prepare and encourage the patient to keep the appointment. The coordinator calls those who miss the initial appointment to reiterate the importance of attendance and to schedule another one. The program has enhanced access to primary care for low-income and uninsured patients, allowing many to establish a medical home.
Date First Implemented
Many uninsured and underinsured patients use the emergency department (ED) for nonemergent conditions that could be better handled in other, lower-cost settings. Many of these individuals have chronic conditions. Frequently they face significant barriers to receiving care outside the ED, and ED staff have no effective way of linking them to a more appropriate source of care. This situation creates many problems for both the patient and health system, including inadequate management of chronic conditions, ED overcrowding, and unnecessarily high costs.
- Many inappropriate ED visits, driven by barriers to accessing primary care: In 2012, nearly half (47 percent) of ED visits in Milwaukee County were classified as nonemergencies.1 In Milwaukee County, Medicaid and uninsured patients accounted for two-thirds of the nonemergent ED visits in 2012.1 Many of these individuals face significant barriers to accessing regular care, including being homeless; having behavioral health or substance abuse issues; and not having adequate insurance, a primary care provider, or reliable transportation to appointments.2
- Inadequate linkages between ED and primary care: Patients who come to the ED for nonemergent care often are encouraged to seek a primary care provider but then do not follow up with those providers. For example, before implementation of this program, ED staff in Milwaukee County routinely encouraged patients to go to a federally qualified health center (FQHC) or other primary care provider for future primary care needs. The attendance rate was only about 20 percent.
- Leading to multiple problems for patients and health system: Frequent use of the ED for chronic, nonemergent conditions creates problems for both patients and the health system, as outlined below:
- Inadequate management of chronic disease: EDs are not set up to provide the multidisciplinary followup care, preventive treatment, care coordination, or patient education and engagement that can improve outcomes for those with chronic health issues. Despite frequent visits to the ED, many chronically ill patients remain undiagnosed and/or inadequately treated.
- ED overcrowding: Many EDs remain overcrowded, in part due to unnecessary use by patients with nonemergent conditions. Between 1996 and 2006, ED visits increased by 32 percent across the country whereas the number of EDs fell by 25 percent. As a result, many EDs have become overcrowded, with hallway boarding of admitted patients, ambulance diversions, and care delays for both minor and serious problems becoming commonplace occurrences. Overcrowding also reduces ED physician productivity and negatively affects the quality of care, particularly with respect to pain management.3
- Unnecessarily high costs: Frequent ED visits from a few “super users” lead to significantly higher costs for the system as a whole.4
Description of the Innovative Activity
The countywide Emergency Department Care Coordination Initiative seeks to reduce future, avoidable ED visits by Medicaid and uninsured patients without an ongoing source of primary care. Providers in eight county emergency departments and four FQHCs and other safety net clinics use a standard process to identify and refer patients in the target population. As part of the ED encounter, an ED-based case manager provides education on appropriate ED use and the importance of having a primary care medical home, and then schedules an appointment at a local clinic through an electronic scheduling system. After the visit, the case manager sends relevant patient information to the clinic. The clinic's intake coordinator follows up by telephone to prepare and encourage the patient to keep the appointment. The coordinator calls those who miss the initial appointment to reiterate the importance of attendance and to schedule another one. A detailed description of key program elements follows:
- Identification of patients using a Health Information Exchange and established participation criteria: Providers at all Milwaukee County EDs review the medical records of patients to determine if they are in the defined target population. Eligible patients include Medicaid beneficiaries and uninsured patients without a medical home who have a chronic condition (e.g., asthma, chronic obstructive pulmonary disease, diabetes, hypertension), have HIV/AIDS, are pregnant, or visit the ED four or more times a year. To help determine eligibility, staff use the region's Health Information Exchange, a computer system that provides an up-to-date, secure, and comprehensive medical history, including diagnoses, medications, allergies, and past visits including to the ED. The system integrates patient records from the county's five major health systems, allowing staff in one ED to see a patient's full history even if he or she previously visited another hospital. (Note: The area is currently in transition from a regional to a statewide health information exchange.)
- Case manager education and appointment scheduling: After ED staff complete treatment of qualified patients, a case manager (social worker or nurse) meets with the patient in the ED, providing education about the need for a medical home and using an electronic application to schedule an appointment at a nearby FQHC or clinic serving the uninsured.
- Patient education on medical home: The case manager explains to the patient the importance of having a medical home and the benefits of getting treated by a primary care doctor, such as ongoing preventive care, access to medications, and management of chronic diseases. Case managers follow a suggested script that program leaders update as needed.
- Scheduling appointment through electronic application: Using scheduling software known as MyHealthDirect that shows available appointments at the county's four FQHCs and other safety-net clinics and standard referral criteria, the case manager schedules an appointment with a primary care doctor at a convenient time for the patient. The case manager gives the patient an appointment confirmation sheet, which includes the date, time, and location of the appointment and information about the safety-net clinic.
- Transmission of information to health center: Before the scheduled appointment, the case manager faxes a summary of the patient's medical record to the receiving safety-net clinic.
- Reminder notice: Several days before the appointment, an intake coordinator at the clinic calls to welcome the patient to the clinic, remind him/her about the upcoming appointment, and review the educational information conveyed by the case manager. Patients who have Internet access or cell phones can also receive appointment reminders via e-mail or text message.
- Follow-up on missed appointments: When patients miss the appointment, the intake coordinator calls to schedule a new appointment and again review the educational information related to a medical home.
Context of the Innovation
The Milwaukee Health Care Partnership is a public-private consortium dedicated to improving coverage, access, and care coordination for underserved populations in Milwaukee County. Consortium members include the county's five health systems (which have nine hospitals that operate EDs), four FQHCs (managing nine clinic sites), Milwaukee's city and county health departments, and the Wisconsin Department of Health Services. Other affiliates include the Milwaukee Free and Community Clinic Collaborative, the Medical Society of Milwaukee County, the Wisconsin Hospital Association, and the Wisconsin Primary Health Care Association.
This program grew out of an increasing awareness among consortium members of two related problems: the large number of patients visiting EDs for conditions that could be treated in lower-cost, nonemergency settings and the large number of Medicaid and uninsured patients without access to primary care. Shortly after the Partnership launched in 2007, members made it a priority to create a community-oriented program to tackle these problems.
The program has enhanced access to primary care for low-income and uninsured patients, allowing many to establish a medical home.
- Enhanced access to primary care: In 2012, case managers in Milwaukee County EDs scheduled more than 6,700 appointments at FQHCs and other safety-net clinics—an average of about 559 per month. Roughly 41 percent of patients scheduled at an FQHC attended their initial appointment. In the absence of this program, many of these patients likely would not have accessed care at the clinics. (Updated July 2014.)
- Many establishing medical home: About 57 percent of patients who kept their first appointment during the second 6 months of 2012 returned for a second appointment within 6 months, suggesting they had made the FQHC their medical home. (Updated July 2014.)
- Reduction in ED visits: Comparing the 6 months pre-appointment with the 6 months post-appointment, an evaluation conducted in 2012 showed that patients who kept their scheduled appointments had a 44-percent reduction in the number of ED visits.
Planning and Development Process
Key steps included the following:
- Committee formation: In 2007, the Partnership formed a steering committee charged with creating a program to reduce avoidable ED visits and related hospitalizations, eliminate duplicative tests and procedures in the ED, and connect Medicaid and uninsured ED visitors with medical homes. Chaired by a health system executive, the committee includes the Partnership's executive director, medical and case management leaders from health system EDs and FQHCs throughout the county, the Wisconsin Department of Health Services' Medicaid Liaison and Medicaid health maintenance organization representatives, and a project coordinator. Soon afterward, the Partnership set up two smaller work groups focused on ED case management and clinic intake, patient engagement, and retention.
- Research to inform program development: Early on, committee members evaluated the many reasons for avoidable ED utilization, reviewed strategies being used by progressive EDs across the country to reduce avoidable visits, and discussed how the nine county EDs handled the issue. In 2008, members of the steering committee participated in the Institute for Healthcare Improvement's “Avoidable ED Utilization” learning collaborative and learned about other municipalities trying community-oriented approaches. Based on this research, committee members coalesced over time around the idea of a community-wide process involving EDs and safety-net clinics using care management strategies and health information technology.
- Incorporation of Health Information Exchange and electronic scheduling system: In 2009, the Partnership began working with four EDs in a pilot that included the first use of the region's Health Information Exchange and the appointment scheduling technology.
- Staff training: Shortly before launch of the pilot, one case manager from each site attended a Partnership-facilitated training session to learn about program processes and tools. This individual took responsibility for teaching other case managers and ED physicians within their organizations about the program using a “train the trainer” model. Intake coordinators from three health centers planning to participate in the pilot test also attended the session.
- Pilot test and rollout: In January 2009, the Partnership launched a 1-year pilot test at the 4 EDs and 3 health centers. The pilot produced encouraging results, with nearly 5,000 appointments scheduled at the 3 centers, roughly 44 percent of patients keeping their initial appointments, and approximately 60 percent of these patients returning for a second visit within 6 months. Based on these findings, the Partnership expanded the initiative to five other EDs, an additional health center, and several free clinics in 2011.
Resources Used and Skills Needed
- Staffing: Many health care workers and support staff play a role in the program as part of their regular duties, including ED nurses; social workers and physicians; and clinic-based intake coordinators, physicians, nurses, and administrative staff. Staff at the Partnership and its member organizations and collaborating partners also work on the program, either as part of their regular duties or on a voluntary basis.
- Costs: Data on total program costs are not available. Major expenses include development and ongoing maintenance of the Health Information Exchange and the MyHealthDirect scheduling software, care management staff in the EDs and FQHCs, and project management and oversight expenses.
Program costs are covered by the participating health systems and FQHCs and the state of Wisconsin. The Robert Wood Johnson Foundation through the Wisconsin Department of Health Services and the Healthier Wisconsin Partnership Program have provided additional support.
Getting Started with This Innovation
- Get high-level sponsorship: Senior-level administrators at all five health systems and four FQHCs, as well as city, county, and State health officials, supported the program from its inception and remain active participants in the Partnership. Their support proved crucial in getting broad acceptance of the program.
- Involve health system and safety-net clinic participants from outset: ED and FQHC physicians, nurses, and social workers provided valuable feedback, such as information on factors that influence how patients use the ED. Their involvement also helped them to understand the Partnership's strong desire to reduce avoidable ED visits and connect vulnerable populations with primary care medical homes.
Sustaining This Innovation
- Make site visits to monitor program: While regular work group meetings can be effective in identifying problems and opportunities for improvement, program leaders should occasionally visit the EDs and safety-net clinics to see the program in action and to elicit ideas from staff about how to improve it.
- Update technology: Program leaders can work with vendors to enhance the program through new features in the Health Information Exchange and scheduling system. For example, the company that manages the scheduling software recently introduced a series of enhancements, including better reporting capabilities and the ability to send appointment reminders via text and to attach relevant materials to messages about scheduled appointments.
- Plan for turnover: Because the program involves many participants, the departure of one individual (such as the intake coordinator at a health center) can interfere with patient flow and implementation of consistent practices across the community. To minimize the potential for disruption, stay in regular contact with all participants and train new employees who will play a role in the program in a timely manner.
Contact the Innovator
Note: Innovator contact information is no longer being updated and may not be current.
Milwaukee Health Care Partnership
2320 North Lake Drive
Milwaukee, WI 53211
Ms. Ragalie reported external funding for the initiative was provided by the Robert Wood Johnson Foundation and the Healthier Wisconsin Partnership Program.
In 2012, the Milwaukee Health Care Partnership was honored as with a Wisconsin Hospital Association (WHA) Global Vision Award. This award recognizes the efforts of WHA members in meeting the documented health needs in their communities through creativity, innovation, partnership, and collaboration. More information is available at: http://www.wha.org/pubarchive/valued_voice/vv9-14-12.htm.
In 2011, the Milwaukee Health Care Partnership was awarded a NOVA award by the American Hospital Association. This award honors effective, collaborative programs focused on improving community health status. More information about this award is available at: http://www.aha.org/about/awards/NOVA.shtml.
Milwaukee Health Care Partnership. Emergency Department Care Coordination Initiative. Available at: http://www.mkehcp.org/wp-content/uploads/2011/08/mhcp_edcc.pdf.
Garcia TC, Bernstein AB, Bush MA. Emergency Department Visitors and Visits: Who Used the Emergency Room in 2007. NCHS Data Brief, No. 38, May 2010. Available at: http://www.cdc.gov/nchs/data/databriefs/db38.htm.
Pitts SR, Niska RW, Xu J, et al. National Hospitals Ambulatory Medical Care Survey: 2006 Emergency Department Summary . National Health Statistics Reports, No. 7, August 6, 2008. Available at: http://www.cdc.gov/nchs/data/nhsr/nhsr007.pdf.
Raven MC, Billings JC, Goldfrank LR, et al. Medicaid patients at high risk for frequent hospital admission: real-time identification and remediable risks. J Urban Health. 2009 Mar;86(2):230-41. Epub 2008 Dec 12. [PubMed]