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Frequent Visitors to the Emergency Department CALENDAR YEAR 2014

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Frequent Visitors to the Emergency Department CALENDAR YEAR 2014 PERFORMANCE TARGET (PT) #1 Frequent Visitors to the Emergency Department CALENDAR YEAR 2014 IMPROVING OUTCOMES & REDUCING UTILIZATION THROUGH INTENSIVE CARE MANAGEMENT, PEER SUPPORT, & SYSTEMS INTERVENTION Submitted: CONNECTICUT December 31, 2014 DCF CONNECTICUT Identification of Emergency Department Super Users and Reduction of Adult Emergency Department (ED) Utilization and Recidivism at Select Hospitals Table of Contents I. Executive Summary .............................................................................................................................1 II. Purpose and Goals ..............................................................................................................................3 III. Introduction ........................................................................................................................................4 Literature Review ............................................................................................................................................. 4 Brief Summary of 2013 Inpatient Performance Target: ED Utilization ........................................................... 5 IV. Methodology .......................................................................................................................................7 Data Set ........................................................................................................................................................... 7 Exclusions ........................................................................................................................................................ 7 Selected Variable Definitions ........................................................................................................................... 8 Research/Statistical Approach .........................................................................................................................10 V. Intensive Care Manager/Peer Model ................................................................................................. 14 VI. Description of the Community Care Team Process ...........................................................................23 VII. ED Prescription Drug Campaign ......................................................................................................34 VIII. Results ...............................................................................................................................................36 Top 10% BH ED & IP High Users ............................................................................................................... 36 Top 2% BH ED Frequent Visitors ..................................................................................................................37 Predictors of BH ED Visitors ......................................................................................................................... 42 Top 10 EDs ................................................................................................................................................... 44 % of ED Visits by BH ED Frequent Visitors ..................................................................................................47 7 & 30 day BH ED Readmissions by Hospital .............................................................................................. 48 7 & 30 day BH ED Readmissions by Frequent Visitors by Hospital .............................................................. 50 7 & 30 day Connect to Care rates by Hospital ...............................................................................................52 7 & 30 day Connect to Care rates by Frequent Visitors by Hospital ............................................................. 54 Geo-Map of Frequent Visitors ....................................................................................................................... 56 Demographics and Other Characteristic of Pilot Participants .........................................................................59 Methodology Changes ....................................................................................................................................73 IX. Proposed Methodology to evaluate rates of primary care ambulatory follow-up .............................. 73 X. Evaluating an Intervention to improve primary care ambulatory follow-up rates ............................ 74 XI. Discussion ......................................................................................................................................... 75 XII. Recommendations .............................................................................................................................79 XIII. Bibliography ...................................................................................................................................... 81 Appendix 1—Evaluation Methodology ................................................................................................................... 82 Appendix 2—Motivational Interviewing Training Curriculum ................................................................................85 Appendix 3—PT Training, ICM Module ............................................................................................................... 97 Appendix 4—Interactive Video Hygiene Training .................................................................................................. 98 Appendix 5—ICM Module Training Follow-up ..................................................................................................... 99 Appendix 6—Peer Support Training Overview ......................................................................................................100 Appendix 7—Universal Precautions Training Curriculum .....................................................................................104 Appendix 8—Copy of PT #1 ................................................................................................................................112 Appendix 9—Copy of SF-12® Patient Questionnaire ............................................................................................ 115 Appendix 10—Copy of PT 1_ED_CORE Status Update – 10-21-14 ...................................................................118 I. Executive Summary Increasing use of the Emergency Department (ED) is a national and international concern. However, few hospitals have developed meth- Increasing use of the ods of identifying those who use the ED the most or interventions to facilitate use of more appropriate community based services. The Emergency Department episodic nature of frequent visiting suggests that to be most effective, (ED) is a national and tools allowing early, real time, accurate prediction of who will become international concern. a frequent visitor should be developed. Since frequent or high users often account for a disproportionately high share of ED visits, there are many advantages to focusing on this population. VO and the CTBHP developed an Intensive Care Manager/Peer Support Intervention (ICM/PEER) to intervene with the top 2% of BH ED Frequent visitors, defined as those with 7 or more ED visits in a 6 month period where there was a BH diagnosis as primary or secondary on the ED claim. Five hospitals were selected for participation in this pilot based on their numbers of ED frequent visitors. The five hospitals are Backus Hospital, Bristol Hospital, Hartford Hospital, St. Francis Hospital and Medical Center, and Yale New Haven Hospital. The goals of the interven- tion were to reduce the percentage of BH ED visits accounted for by Frequent Visitors, reduce BH ED Readmission Rates, and improve connections to care following an ED visit. The ICM/PEER model was developed based on two evidence-based care strategies; Motivational Interviewing (MI) and Wraparound or WRAP. The development/enhancement of Community Care Teams (CCT) was a second strategy employed in conjunction with the ICM/PEER Intervention to better serve frequent visitors to the ED. CCTs bring hospital EDs together with key community resources to engage in client specific planning and coordination. VO is learning that to be successful a CCT must have high level buy-in, commitment and participation from multiple hospital departments (including the ED) and key community agencies and support networks. Keys to success have included successful negotiation of legal issues related to implementing a broad release of information for all CCT participants, resources and key players to lead the CCT and provide organizational support, and access to technology for timely information sharing related to care planning and coordination. A sub goal of the PT was to identify the “High Users” of both inpatient care and the ED defined as the top 10% of highest utilizers of both services. There was significantly less overlap between these populations than originally anticipated with a minority of those that visit the ED (26%) being high users of the hospital and just over half of those that are hospitalized (53%) being high users of the ED. For now, it is suggested that separate strategies for dealing with Inpatient or ED High Users is the best approach. The current study confirmed previous research indicating that most frequent visitors do not persist in their frequent use of the ED. Further detailed study of both persistent and episodic frequent visitors is indicated. The current study confirmed
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