Emergency Department
Disposition Support
Dr. Bruce Muma, Dr. Michelle Slezak
March 22-25, 2017
Dr. Muma and Dr. Slezak do not have anything to disclose.
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Agenda
• Henry Ford Health System Overview
• The Opportunity
• EDS Model
– Metrics
– Business Case
– Patient Impact
• Keys to Success
• 2017 Spread Plan
• Questions
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About Henry Ford Health System
• Henry Ford established an integrated hospital in 1915
• 30,000 employees / $6B in Gross Revenue
– Fourth largest employer in Metro Detroit
• Henry Ford Hospital (HFH)
– 802-bed academic medical center
– 16th largest teaching hospital in the U.S.
• Clinically Integrated Network
– CMS ACO
• Next Generation Model (25,000 beneficiaries)
• HFMG: 1,200 physicians and researchers
• Independent Practice: 250 Employed and Private
– Henry Ford Physician Network
• Commercial ACO (40,000 covered lives)
• 2,000+ Physicians
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About Henry Ford Health System
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Community Hospitals:
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Macomb-Clinton Township
Wyandotte
West Bloomfield
Allegiance
Behavioral Health (3 facilities)
Ambulatory Facilities:
– 46 Ambulatory sites, including medical centers, outpatient surgery, urgent care and
emergency services
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Community Care Services
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Full Pharmacy Services: OPD, PBM, Specialty, home infusion
DME
Optometry
Dialysis
Home Health Services
Provider Based Health Plan: Health Alliance Plan Insurance
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The Opportunity
• Sudden acceleration on the journey to value
– New Next Generation ACO with upside and downside risk (+/- 80%)
– Full risk for internal HMO network contracts (MA, Commercial)
– Partial risk for selected external HMO contracts
• Tipping Point:
– ~30% of provider revenue with “downside” risk
– ~85% of provider revenue from value based contracts
• Strategic approach:
– Rapidly identify important points on the continuum with opportunity
– Promote integration of clinical services to eliminate waste
• Improving reliability and effectiveness of high cost/high risk care processes
• Reduce variation in high cost/high risk medical decision making
• Align resources to better serve high cost/high risk population needs
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Where is the Waste?
Where should we
deploy resources to
quickly impact the
largest area of waste?
Ambulatory Care
Clinic Care
High Cost Decision
High Provider Variation
Poor Hospital Revenue Stream
Urgent/Emergent Care IPD Care
Post Acute Care
Transitional Care,
Reduce Variation in
Length of Stay,
Disease Management,
Admission Thresholds,
Readmission Rates
Virtual Care, Timely
Provide Follow Up
Access, Case
Resources and
Discharge Planning,
Management
Provider Feedback
Transitional Care, Reduce
Loops
Variation SNF Transfer
Decisions, Reduce HAC’s
Reliable, Effective
Processes, No Missed
Need interventions with rapid
Opportunities,
deployment and maximal impact
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How large is the opportunity?
How many admission requests did not meet Interqual criteria?
Based on 2015 data, out of 1,116 admission requests for HFMG assigned MA
patients that did not meet IPD level of care admission criteria:
481 were admitted by standard protocol without physician review
635 were sent for physician review
41% resulted in IPD admission
59% resulted in observation admission
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How large is the opportunity?
How much “admission decision” variation exists between hospitals, EDs, and
providers?
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How do we create sustainable value?
How do we avoid borderline admissions?
Where do we have the opportunity to impact?
We met with ED leadership to develop a collaborative partnership and discuss a better
way to approach avoidable admissions, and came up with an intervention that would:
• Make outpatient and other resources available for ED patients within 24-48 hours of
ED discharge
• Offer these resources to ED providers
• Coordinate the resources selected by ED providers prior to patient’s discharge from
the ED
• Estimated that an avoidance rate of 5% was possible to achieve in the first year
EDS (EMERGENCY DISPOSITION SUPPORT) PROGRAM IS BORN!
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EDS Model
• Created a new role called a “Navigator” to support physicians in their quest
to implement alternatives to a hospital admission or observation stay
• The EDS “Navigator” is:
– A licensed Emergency Medical Technician (EMT)
– Embedded in the ED
– Trained to collaborate with physicians to implement a wide variety of outpatient
resources
• Initial implementation in Henry Ford Hospital ED
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EDS Workflow
• EDS Navigator follows ED track board to identify targeted patients
• Best practice alerts fire in Epic when a provider opens the chart of a patient
in the EDS population
– Alert for ED provider to discuss case with EDS Navigator
– Alert stays in background of chart
• “On call” EDS physician available on cases that aren’t straightforward
– Also provides coverage for paramedic team
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ED
Physician
ED Nurse
Patient
EDS
Navigator
Rest of
the Care
Team
Navigator Toolbelt
Navigator Tool Belt
Schedule Appointments:
Urgent Ambulatory
Primary Care
Specialty
Diagnostic Testing
(Cardiac Stress test)
Ambulatory Case
Management
Community
Paramedicine*
Home Health Care
SNF Direct Admit
Appointment with
Certified Diabetes
Educator
Transportation/DME
Scheduling treatment
(Missed Dialysis)
OncoSTAT Clinic for
oncology patients
*Pending implementation
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Navigator Tool Belt (Interventions)
• Arrange urgent ambulatory appointments
– Schedule appointment with PCP
– Schedule appointment with Comprehensive Care Center when appropriate
• Refer to ambulatory case management
– Update assigned case manager
– Refer for case management
• Arrange community paramedic visits (design in process)
– Paramedic visits patient in the ED
– Additional visit shortly after discharge from ED
– Maintains stability until ambulatory appointment
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Navigator Tool Belt (Interventions)
• Facilitate home care referrals
– Expedite urgent referrals to home care
• Facilitate direct admission to Skilled Nursing Facilities from ED
– Henry Ford ACO waiver eliminates CMS’ 3-day IP requirement
– Hap MA require prior authorization
• Facilitate appointment with a certified diabetes educator
• Arrange durable medical equipment (DME)
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Navigator Tool Belt (Interventions)
• Arrange Transportation
– Available community resources explored for patient
• Facilitate scheduling specialist appointment
– Assisted by RPO with EDS iPAS physician collaboration
• Facilitate scheduling diagnostic appointment
– i.e. stress test
• Facilitate scheduling treatments
– Missed dialysis appointments
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Community Paramedicine
Used in cases in which an urgent ambulatory appointment has been scheduled and the
patient needs to be monitored between ED discharge and the appointment.
Paramedic visits • Treatment plan created
• Inbasket message sent to PCP and EDS iPAS
patient in ED
Paramedic visits
• Home/patient assessment
patient at home
Additional 1 -2
visits until PCP
appt/HHC visit
• Vital signs
• Changes in condition
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Community Paramedicine Physician Support
EDS IPAS Physician
PCP
0-48 hours from ED
discharge
48+ hours from ED
discharge
PCP
Appointment/HHC
Visit
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Continuous Improvement
• Implemented daily management system
• Implemented weekly huddles with Plan-Do-Check-Act (PDCA) cycles
• Added continuous improvement training to orientation plan for EDS
Navigators
• Engagement of stakeholders during planning phase, and quarterly meetings
with stakeholders after go-live
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Continuous Improvement – Weekly Huddle
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Continuous Improvement – PDCA
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Continuous Improvement – Stakeholder Meetings
• Site specific stakeholder meetings held 30, 60, and 120 days post launch
• System stakeholder meetings held quarterly
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Metrics
• We worked closely with analytics to create a dashboard to
measure our progress and impact
• The dashboard shows:
– Population demographics
– Process metrics
– Outcome metrics
• The dashboard is updated weekly and is used during huddles,
as well as for other system leadership updates
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Process Metrics – Average ED Length of Stay
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Process Metrics – YTD Avoidances
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Process Metrics – Facilitated Interventions
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Outcomes
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Program Impact
• We have estimated the potential impact of the EDS program
based on:
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Volume projections
Current avoidance rates
2016 Upgrade rates from observation to IPD admission
Variable cost savings
Claims expense savings
Program cost
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Program Impact
Assuming a fully capitated arrangement, we estimate the following impact of
the program:
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Program Impact
From a hospital perspective…
Total Variable Cost Savings
- Total Estimated Cost of Program
= Total Estimated Savings for 2017
$1,189,985
$640,171
$549,814
From a health plan perspective…
Total Claims Expense Savings
- Total Estimated Cost of Program
= Total Estimated Savings for 2017
$2,909,086
$640,171
$2,268,915
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Patient Impact – Survey
Patient Survey
Mailed out Weekly
Vetted by Patient
Focus Group
9 Question Survey
Developed by
Health Sciences
Department
Analytics provides
MRNs
Cover Letter
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Patient Impact – Story
• An oxygen dependent COPD patient presented to the HFH ED following the
loss of power in her neighborhood
• Because she had no backup oxygen, it required she stay in the ER overnight
• When her power came back on, her oxygen concentrator was no longer
working, so the ED provider wanted to place the patient in observation
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Patient Impact – Story
• The EDS Navigator:
– Called the patient’s electrical provider and arranged for her to be put on the list
of customers needing power for medical equipment
– Called the medical equipment company and negotiated a timeframe for them to
fix or replace the patient’s concentrator, and provide the patient with two
portable oxygen tanks in case of future emergency
– Coordinated with an ambulance service to transport the patient and let the
technician in the home
• In the end, the patient was able to go home instead of being placed in
observation
• The granddaughter was relieved that her grandma was not just home, but
was prepared in case the power went out again
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Patient Impact – Feedback
• Patient was happy to hear she didn’t have to stay the night. She had a
daughter at home that she had to take care of.
• Patient was very grateful to hear that she could get into see a Neurologist so
quickly. She had an appointment that was 3 months out from the date she
scheduled it.
• Patients family was very pleased at the fact the patient was able to go to her
SNF from the ED instead of being admitted.
• Patient’s family was shocked that he wasn’t admitted and could get home
health care.
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Keys to Success
• Collaboration with ED stakeholders throughout the project
– Stakeholder retreat before pilot launch
– 30, 60, and 90 day stakeholder meetings
• Strong physician champion
• Stakeholder involvement to help with design of the program
• Communication with system leadership
• Flexible team members
• Performance Improvement training with EDS team members
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Spread Plan for 2017
Our spread plan for 2017 is based on hospital (medical group first) and volume
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Questions?
3
7
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