Description: Practice can demonstrate reduction of Low Acuity Non Emergent (LANE) visits to the Emergency Room
What does success look like?
The MidSouth PTN has set out to reduce ED visits across our network by a relative 5% over the next year and by a relative 20% at the end of Year 4.
Why is this important?
Emergency Departments frequently function outside of their intended role to provide emergency care. Inappropriate and costly visits to the ED are associated with a number of preventable factors that include: 1) patients lacking access to timely primary care, 2) patient referrals to the ED because of limited access to timely specialty care, and 3) inability to get psychiatric care and treatment.1 These Low Acuity Non-Emergent (LANE) ED visits, defined generally as visits for which a delay of several hours would not increase the likelihood of an adverse outcome, account for 30% of all emergency department visits.2 Non-urgent visits often indicate insufficient access to coordinated care and result in unnecessary testing and treatment that results in significant preventable costs to the healthcare system.1 An estimated $4.4 billion could be saved annually if non-urgent ED visits were seen in clinic settings;2,3 this estimate does not account for additional cost burden from over utilization of ED visits for specialty care services.
“Super utilizers” (individuals with 4 or more ER visits per year) are a small group of patients (4.5%-8%) that account for an estimated 28% of all ER visits, increasing the potential impact of reduction efforts targeted at this population.2 Another potentially impactful target population are high utilizers with behavioral health or substance abuse problems that account for approximately 12.5% of ED visits nationwide.4 Successful efforts to reduce unnecessary ER visits – and their associated costs – need to be addressed by increasing access to both primary and specialty care services in a timely manner.4
- After-hours access: Practices that implement after hours call systems that allow patients to access care providers have been seen to reduce the frequency of patients going to the ED unnecessarily
- Specialist Collaboration with Primary Care Physician: Specialists should consider contacting a patient’s primary care provider prior to recommending a patient go to the ED to determine if a PCP clinic visit is appropriate.
- Patient alerts: Partnerships with local Emergency Departments can create protocols to alert your practice when your patients are seen in the ED, letting your practice set follow up appointments to see the patient in clinic the next day.
- Tracking ED visits: Working with local hospitals to receive monthly reports about ED visits of patients affiliated with your practice can help identify key opportunities to prevent future non-urgent ED visits.
- Collaboration on care with the local ED: Developing a relationship with the local ED can help to develop shared approaches to care for patients that could help to reduce unnecessary emergency department visits and hospitalizations. For example, providers can work with local EDs to develop approaches for the prescription of controlled substances such as narcotics, and for management of common conditions (ex. cellulitis, deep vein thrombosis, heart failure, etc.).
- Community Partnerships: collaborations with local resources, such as urgent care clinics, can provide after-hours and weekend coverage for patients while ensuring coordinated care. See the case example above.
- Patient education: Voice messaging systems should clearly indicate how to reach an on-call physician or answering service for non-emergent requests. Similarly, education of patients regarding after hours needs should be provided during standard care visits, particularly focusing on high utilizers.
Tools and Resources
What might this look like in practice?
A pilot project within the MidSouth PTN: A group of pediatricians reviewed their own practice data and found that 30% of ED visits among their patients could have been managed in the clinic. Next, they interviewed patients to identify reasons parents were choosing to go to the ED instead of scheduling a clinic appointment. Two primary reasons were noted:
- Most parents took their child to the ED if the pediatrician’s office was closed or could not work them in for an appointment that day
- Many EDs have low wait times and are closer than the pediatrician’s office, making it a more convenient option.
One dedicated pediatrician set out to reduce LANE visits to the ED by creating a clear after-hours coverage plan that included extended office and weekend hours as well as an answering service. He partnered with a retail urgent care clinic near his practice and piloted a program with three key elements:
Continuity of Care: Whenever a provider at the retail clinic treated a patient who self-identified the pediatrician as his/her primary care physician (PCP) an encounter form was faxed to the pediatrician’s office at the end of the visit. If necessary, a follow-up appointment was then scheduled with the PCP.
Quality Care: Leadership had concerns about partnering with retail clinics that may not follow standard protocols. In response, a clinical guideline exchange was created to share best practice protocols between the PCP practice and the retail clinic. Additionally, the pediatrician provided monthly feedback for improvement to the retail clinic based on patient chart review.
PCP referrals: Patients who indicated that they did not have a primary care provider were referred to a physician within the network.
Results: This pilot collaboration was able to reduce ED visits per 1,000 patients by 52% in the first year (from 120 to 58). Comparable practices reduced ED visits per 1,000 members by 2% during the same period. Since imaging is more common in Emergency Departments than in a pediatrician’s office, this pilot was estimated to generate a 30% reduction in X-ray use and 70% reduction in MRI utilization, both resulting in cost savings. Finally, this pilot showed promise for a model that will allow physicians to maintain a good work-life balance while maintaining quality continuous care for patients, improving both physician and patient satisfaction.
- Burke and Paradise. Safety-Net Emergency Departments: A Look at Current Experiences and Challenges. Kaiser Family Foundation Issue Brief. Feb 10, 2015.
- Uscher-Pines L, Pines J, Kellermann A, Gillen E, Mehrotra A. Deciding to Visit the Emergency Department for Non-Urgent Conditions: A Systematic Review of the Literature. Am J Manag Care. 2013 Jan;19(1):47-59.
- Weinick RM, Burns RM, Mehrotra A. Many emergency department visits could be managed at urgent care centers and retail clinics. Health Aff (Millwood). 2010;29(9):1630-1636.
- Mann, Cindy. CMCS Informational Bulletin: Reducing Nonurgent Use of Emergency Departments and Improving Appropriate Care in Appropriate Settings. Centers for Medicare & Medicaid Services. January 16, 2014.