The Emergency Department (ED) is often at the center of some of the most controversial issues in health care reform. The cost of care, coordination of care, avoidable hospitalizations, misuse of the ED, and other issues have challenged hospitals to keep costs under control while delivering timely access, efficiency, and quality. Today's challenges certainly create an imperative for change. But more importantly, hospitals must respond to a rapidly evolving health care environment, where the typical approach may not only become obsolete, it may be perilous. Preparing for the future will require substantial changes. An accurate “diagnosis and treatment plan” is essential. And getting this “right” matters.

1. RIGHT-SIZING THE EMERGENCY
DEPARTMENT IN HEALTH CARE REFORM
MODERN HEALTHCARE WEBINAR – OCTOBER 8, 2014

2.  Randy Pilgrim, MD, FACEP
Enterprise Chief Medical Officer
 Jesse M. Pines, MD, MBA, MSCE
Director of the Office for Clinical Practice Innovation
Professor of Emergency Medicine and Health Policy
 Brent R. Asplin, MD, MPH
Chief Clinical Officer
2
PRESENTERS

3. RIGHT – SIZING
THE EMERGENCY DEPARTMENT
IN HEALTH CARE REFORM
3

4. EMERGENCY MEDICINE IN HEALTH REFORM
 Emergency Departments must continue to deliver excellent
care for acute illness and injury.
 Traditional functions must be refined and enhanced.
 Changing the traditional approach to intermediate and
complex conditions results in significant near-term value.
 The Emergency Department will redefine key functions:
▪ Patient care coordination
▪ Best use of the health care system
 Building early organizational capacity and capability is key.
▪ Get ahead of the curve
▪ Build a plan
▪ Start now
4

5. IN THIS WEBINAR, WE ADDRESS:
 Fundamental drivers of change that impact the ED
 Tactics for short term effectiveness
and long term readiness
 Functions in the ED that should be augmented,
newly created, or curtailed
 Preparing for new reimbursement models
 Frameworks for assessing the readiness of your ED
for change
5

6. HEALTH CARE
AND
THE EMERGENCY DEPARTMENT:
BACKGROUND AND PERSPECTIVES
6

7. EMERGENCY MEDICINE:
FACTS & REALITIES
 ED treats a broad range of medical and surgical
conditions
▪ 130 million annual ED visits in the U.S.
▪ Emergent care: 10-16% of visits
▪ Intermediate/complex conditions: 31-57% of visits
▪ Minor conditions: 12-40% of visits
 Emergency care represents 7-11% of health care costs
7

8. EMERGENCY MEDICINE:
FACTS & REALITIES
 The ED as the hub of the enterprise:
▪ Patient experience and community perception
▪ Quality measures
▪ Market share and revenue
▪ Medical staff satisfaction
▪ Utilization and cost
8

9.  Existing demand for ED care
 Broad range of patients
 High fixed cost
 Center for decision-making
▪ Hospitalization
▪ Advanced imaging
▪ Coordination of care
 Centralized management hub
▪ Prioritization and implementation of initiatives
▪ Flexibility for rapid-cycle adjustments
 24/7 availability
9
WHY LEVERAGE THE ED?
9

10. “RIGHT-SIZING” THE ED INVOLVES:
1. The ED itself
 Foundations and fundamentals
 Expand care coordination
2. Right-sizing key interfaces
 Admissions
 Near-admissions
3. Right-sizing patient care after the ED encounter
 Transitions of care
 Patient care follow up
4. Right-sizing utilization of the ED
 Best use of the health care system
10

11. 11
Recent Changes
• Two-midnight rule compliance
• Readmission prevention
• Quality measure compliance
• HCAHPS (and ED-CAHPS) performance
• Certification & regulatory standards
• Documentation for hospital-acquired conditions
• Care transition management
Foundations
• Acute treatment of sick & injured
• Treatment of time-sensitive conditions
• Rapid diagnostic center
• EMS direction and coordination
• Disaster preparedness & response
• Safety-net care
After the ED Visit
(For post-ED patients with high-cost conditions)
• Telemonitoring
• Primary care integration
• Patient engagement strategies
• After-care visits
• Care management
• Assistance with palliative care
• Disease management
• Medication monitoring
Before the ED Visit
• Assist employees/employers with
optimal site of care for certain
illnesses or injuries
• Assist patients with access to office-based
care
• Coordinate care with health plans
• Manage care-seeking behavior
• Direct patients to best site of care
KEY DRIVERS OF CHANGE
 Value-based purchasing
 Novel payment mechanisms
 Cost management imperatives
 Fragmentation of care
 Insufficient access to primary care
 Emergency department crowding
 Overall reductions in revenue per
patient
Expanded ED functions Coming Soon:
Beyond the “Four Walls”
Core ED Functions
ED-Focused Outcomes
The Emergency Department
as a Value-Driven Asset
© 2014
Key Hospital Outcomes
Value-Driven Health System
Coordination & Continuity
Evolving Care
• Treatment of intermediate conditions
• Treatment of complex chronic conditions
11

12. POLL QUESTION
 What is the most important way that EDs need to
change to improve value in health care?
A. Increase in size to accommodate higher demand and
reduce crowding
B. Expand services to enhance care coordination with non-ED
physicians
C. Decrease in size so patients can go to more appropriate
settings
D. Work on internal processes to improve treatment pathways
12

13. RIGHT-SIZING THE ROLE OF THE
EMERGENCY DEPARTMENT
13

14. EMERGENCY MEDICINE IN HEALTH
REFORM
 The ED must have excellent foundations
 Acute illness and injury
 Time-sensitive conditions
 Undifferentiated conditions
 Unscheduled care
 Traditional functions must be refined and enhanced
 Active management of care transitions
 Integration with broader health system
 Value-driven care
 Changing the approach to intermediate and complex conditions may
result in significant cost-efficiency
 Building early organizational capacity and capability is key
 Responding to changes
 Getting ahead of the curve
 Build a plan
 Start now
14

15. 15
Foundations
• Acute treatment of sick & injured
• Treatment of time-sensitive conditions
• Rapid diagnostic center
• EMS direction and coordination
• Disaster preparedness & response
• Safety-net care
ED-Focused Outcomes
The Emergency Department
as a Value-Driven Asset
© 2014
Key Hospital Outcomes
Value-Driven Health System
Coordination & Continuity
Expanded ED functions Coming Soon:
Beyond the “Four Walls”
Core ED Functions
15

16. RIGHT-SIZING THE ED ITSELF
FUNDAMENTALS & FOUNDATIONS
 Space and equipment
 Provider staffing
 Effective leadership
 Quality Care
▪ Acute treatment of sick and injured
▪ Time-sensitive conditions
▪ Rapid Diagnostic center
▪ EMS direction and coordination
▪ Disaster preparedness and response
▪ Safety net care
 Departmental efficiency
▪ Input
▪ Throughput
▪ Output
16

17. 17
Recent Changes
• Two-midnight rule compliance
• Readmission prevention
• Quality measure compliance
• HCAHPS (and ED-CAHPS) performance
• Certification & regulatory standards
• Documentation for hospital-acquired conditions
• Care transition management
ED-Focused Outcomes
The Emergency Department
as a Value-Driven Asset
© 2014
Key Hospital Outcomes
Value-Driven Health System
Coordination & Continuity
Expanded ED functions Coming Soon:
Beyond the “Four Walls”
Core ED Functions
17

18. RIGHT-SIZING THE ED ITSELF
RECENT CHANGES
 Quality measure compliance
 HCAHPS (and ED-CAHPS) performance
 Readmission prevention
 Two-midnight rule compliance
 Hospital-acquired conditions (HACs)
 Certification and regulatory standards
 Care transition management
18

19. 19
ED-Focused Outcomes
The Emergency Department
as a Value-Driven Asset
© 2014
Key Hospital Outcomes
Value-Driven Health System
Coordination & Continuity
Expanded ED functions Coming Soon:
Beyond the “Four Walls”
Core ED Functions
Evolving Care
• Treatment of intermediate conditions
• Treatment of complex chronic conditions
19

20. RIGHT-SIZING EMERGENCY CARE
TRANSITIONS INTO THE HOSPITAL
TRANSITIONS TO THE COMMUNITY
A. CRITICALLY ILL, COMPLEX PATIENTS
B. LOW ACUITY PATIENTS
C. MODERATELY COMPLEX CONDITIONS
COMPLEX CHRONIC CONDITIONS
(clear hospitalizations)
(clear discharges to home)
(possible hospitalizations)
20

21. RIGHT-SIZING EMERGENCY CARE
CRITICALLY ILL / COMPLEX PATIENTS
 Examples:
 Multiple trauma
 STEMI
 Stroke
 Early identification of sepsis
 Opportunities (keys to right-sizing):
 Agreed-upon care pathways
 Effective communication and transitions of care
 Quality measurement and optimization
 Utilization reviews
 Proper documentation
 Provider feedback
 Efficient patient flow is still a high priority
21

22. RIGHT-SIZING EMERGENCY CARE
LOW ACUITY PATIENTS
 Examples:
 Upper respiratory infection
 Acute otitis
 Ankle sprain
 Opportunities (keys to right-sizing):
 Clear discharge instructions
 Patient teaching
 Clear plan and referral for high value after-care
 Education about best use of health care options
 (ED, primary care, urgent care, etc.)
 Efficient patient flow is still a high priority
22

23. CHANGING THE APPROACH TO
INTERMEDIATE & COMPLEX CONDITIONS
 Hospital admissions account for approximately 31% of health care
cost
 Over half of hospital admissions come through the ED
 Intermediate and complex conditions account for 75-80% of these
admissions
 Examples: CHF, COPD, Diabetes, UTI, pneumonia, abdominal pain, chest
pain
 Hospitals can generate significant cost-efficiencies by addressing
testing, treatment, and hospitalization patterns for intermediate
and complex conditions
 These account for 31-57% of all ED visits
 Reducing hospitalization in this group by 10-25% would save 1-2.5% of
all health care costs ($28B - $70B annually)
23
* “A Novel Approach to Identifying Targets for Cost Reduction in the Emergency Department.”
Smulowitz, Peter B., et. al.
Health Policy/Concepts, Annals of Emergency Medicine. 2012
23

24. RIGHT-SIZING EMERGENCY CARE
MODERATELY COMPLEX CONDITIONS
CHRONIC CONDITIONS
 Examples:
 Complex chronic conditions:
 Congestive heart failure
 COPD
 Diabetic complications
 Acute presentations:
 Opportunities (keys to right-sizing):
 Pneumonia
 Abdominal pain
 Atypical chest pain
 Identify high-frequency or high-risk groups
 Engage providers to determine care pathways
 Create alternative hospital-based resources, such as:
 ED observation units
 Dedicated rapid treatment units
 Hospitalist or specialist consultation with in ED
 Consistently utilize the mechanism that delivers value & efficiency
 Identify clinical and practical solutions to patient groups that require
longitudinal care after ED treatment
 Ensure seamless coordination of care and provider communication
 Plan for timely follow-up
24

25. RIGHT-SIZING EMERGENCY CARE
MODERATELY COMPLEX CONDITIONS
CHRONIC CONDITIONS
 Time, resources & space are required
 Time-based throughput goals are a secondary priority
 Diagnostic precision and care coordination is
paramount
25

26. POLL QUESTION
 At this time, do you think your ED should change
its approach to intermediate and complex
conditions?
A. Yes
B. Yes, but not now
C. Not now and probably not later, either
26

27. OUTSIDE THE FOUR WALLS:
PREPARING FOR THE FUTURE
27

28. OUTSIDE THE FOUR WALLS
PREPARING FOR THE FUTURE
 Right-sizing patient care after the ED
encounter
 Transitions of care
 Patient care follow up
 Right-sizing utilization of the ED
 Best use of the health care system
28

29. 29
After the ED Visit
(For post-ED patients with high-cost conditions)
• Telemonitoring
• Primary care integration
• Patient engagement strategies
• After-care visits
• Care management
• Assistance with palliative care
• Disease management
• Medication monitoring
ED-Focused Outcomes
The Emergency Department
as a Value-Driven Asset
© 2014
Key Hospital Outcomes
Value-Driven Health System
Coordination & Continuity
Expanded ED functions Coming Soon:
Beyond the “Four Walls”
Core ED Functions
29

30. RIGHT-SIZING PATIENT CARE AFTER THE
ED VISIT
 Appropriate transitions of care
 Care coordination
 Case management and disease management (home monitoring,
medication management, follow-up clinic, etc.)
 Primary care (assignment, availability, appointment, visit
assurance)
 Other follow-up care (medication checks, etc.)
 Palliative care
 Telemedicine solutions
 Use the ED as a “Canary in the Coal Mine”
 Early warning system
 Indicator of processes and resources needed to optimize value
30

31. 31
Before the ED Visit
• Assist employees/employers with
optimal site of care for certain
illnesses or injuries
• Assist patients with access to office-based
care
• Coordinate care with health plans
• Manage care-seeking behavior
• Direct patients to best site of care
ED-Focused Outcomes
The Emergency Department
as a Value-Driven Asset
© 2014
Key Hospital Outcomes
Value-Driven Health System
Coordination & Continuity
Expanded ED functions Coming Soon:
Beyond the “Four Walls”
Core ED Functions
31

32. RIGHT-SIZING UTILIZATION OF THE ED
 Patient education on choosing site of care
(in the context of local health care resources)
 Systems for managing care-seeking behavior
 Mutual efforts with employers and payors
 Managing high cost utilizers
 Deploying innovative solutions (telemedicine, etc.)
 Creating alternatives for low-acuity care that could be
managed in other settings
▪ Primary care
▪ Urgent care
▪ Options for uninsured
▪ Employer-driven options
32

33.  Estimates of preventable ED visits vary widely
(10-40% of all ED visits)
▪ Some rely on final diagnosis, rather than presenting condition
▪ Non-emergent visits cannot be reliably predicted based on
presenting complaint (Raven, et. Al.)
 Low-acuity visits still need medical care
▪ They also incur costs, which must also be considered
 Even so, eliminating half of all ED visits for minor illness or
injury results in saving only 0.2 – 0.8% of all health care
costs. (Smulowitz, et.al.)
▪ Much smaller impact than intermediate/complex conditions
▪ Complicated by EMTALA mandate & prudent layperson standard
▪ Difficult management
33
WHAT ABOUT PREVENTABLE ED VISITS?
33

34. 34
34

35. TAKE HOME POINTS
35

36. FAST CARE AT ALL COSTS FOR ALL PATIENT TYPES
WON’T WORK ANYMORE
 Take necessary time to address moderate complexity
patients potentially requiring hospitalization.
 This is perhaps the greatest near-term potential for
enhanced value for the ED.
 Requires:
▪ Clear clinical strategies
▪ Different processes in ED
▪ Space
▪ Sufficient staff
36

37. ATTEMPTING TO AVOID THE ED AT ALL COSTS
IS UNLIKELY TO PRODUCE THE GREATEST VALUE
 However, cost-efficient alternatives to ED care for certain
conditions may be valuable for hospitals, health systems,
and patients.
 Alternatives must be readily available, timely, and accessible.
 Alternatives must also coordinate care with other elements of the
system.
 If no timely or accessible alternatives exist, efficient utilization of
the ED is best, with concurrent patient education.
 Cost-efficiency requires scale, availability, and partnerships.
 Requires significant effort (and resources)
37

38. THE SAFETY NET FUNCTION OF THE ED MUST BE
RECOGNIZED AND ACCOMMODATED
 Most communities and delivery systems will continue to
struggle with availability and access to primary care.
 EMTALA requirements and the prudent layperson standard
will continue to force cost-shifting.
 Lower reimbursing payers do not cover the cost of care.
 Comparing the cost of ED care with other settings is difficult.
 Health care safety net comes at a cost.
 Standby and surge capacity comes at a cost.
 Capability for treating a large range of conditions comes at a cost.
 Reinforces the need to leverage the ED’s fixed costs.
38

39. THE ED IS AN IMPORTANT SECONDARY HUB FOR
MANAGING THE HEALTH OF POPULATIONS
 Leverage the ED’s position at the interface of ambulatory and
inpatient care.
 When appropriately resourced, the ED can be a key setting for:
 preventing ambulatory care sensitive admissions and readmissions
 connecting patients to primary care
 Forward-thinking organizations must embrace the role of the ED
in bending the healthcare cost curve.
 Patients with the highest healthcare spending will end up in the ED.
 Must build strong connections:
 for hospitalized patients
 back to the ambulatory care continuum
39

40. EMERGENCY DEPARTMENT
 Increasingly identified as a strategic asset
for hospital-based care
 Can be leveraged to address significant issues
for hospitals and health systems
 Must be:
 Effective in today’s environment
 Right-sized for the future
 Optimized for health care value in both
40

41. 41
Recent Changes
• Two-midnight rule compliance
• Readmission prevention
• Quality measure compliance
• HCAHPS (and ED-CAHPS) performance
• Certification & regulatory standards
• Documentation for hospital-acquired conditions
• Care transition management
Foundations
• Acute treatment of sick & injured
• Treatment of time-sensitive conditions
• Rapid diagnostic center
• EMS direction and coordination
• Disaster preparedness & response
• Safety-net care
After the ED Visit
(For post-ED patients with high-cost conditions)
• Telemonitoring
• Primary care integration
• Patient engagement strategies
• After-care visits
• Care management
• Assistance with palliative care
• Disease management
• Medication monitoring
Before the ED Visit
• Assist employees/employers with
optimal site of care for certain
illnesses or injuries
• Assist patients with access to office-based
care
• Coordinate care with health plans
• Manage care-seeking behavior
• Direct patients to best site of care
Expanded ED functions Coming Soon:
Beyond the “Four Walls”
Core ED Functions
ED-Focused Outcomes
The Emergency Department
as a Value-Driven Asset
© 2014
Key Hospital Outcomes
Value-Driven Health System
Coordination & Continuity
Evolving Care
• Treatment of intermediate conditions
• Treatment of complex chronic conditions
KEY DRIVERS OF CHANGE
 Value-based purchasing
 Novel payment mechanisms
 Cost management imperatives
 Fragmentation of care
 Insufficient access to primary care
 Emergency department crowding
 Overall reductions in revenue per
patient
41

42. QUESTIONS
42

43. ADDITIONAL RESOURCES
 Emergency Care and the Public’s Health
 Edited by Dr. Jesse Pines
 A Novel Approach to Identifying Targets for Cost
Reduction in the Emergency Department.
 Smulowitz, Peter B., et. al. (2012). Health
Policy/Concepts. Annals of Emergency Medicine.
 Modern Healthcare Perspectives:
 Right-Sizing the Emergency Department in Health
Care Reform
 ModernHealthcare.com/Perspectives_Schumacher
 ED Rapid Assessment Tool
 ed-assessment.schumachergroup.com
43

44. RIGHT-SIZING THE EMERGENCY
DEPARTMENT IN HEALTH CARE REFORM
MODERN HEALTHCARE WEBINAR – OCTOBER 8, 2014