This document summarizes a successful CMS demonstration project between a Federally Qualified Health Center (FQHC) and a partner hospital to decrease unnecessary emergency room visits and coordinate care. The project utilized shared health IT systems, assigned personnel to coordinate care between the organizations, and provided patient education to redirect non-emergency visits to the FQHC for timely care. Results showed an 82% follow through rate for FQHC appointments from emergency visits, sustained primary care engagement rates of 49-90%, and decreased emergency room time to admission. The collaboration reduced healthcare costs while improving outcomes through coordinated care and patient education.

1. BOLSTERING PERFORMANCE,
AFFILIATIONS FOR
FUTURE CARE
NATIONAL HEALTHCARE CMO SUMMIT
SEPTEMBER 2019
RAKSHA JOSHI, FACOG, FRCOG, (FAAPL)FACPE, CPE, MBA, MD
CHIEF MEDICAL OFFICER AND MEDICAL DIRECTOR
MONMOUTH FAMILY HEALTH CENTER
LONG BRANCH; NEW JERSEY

2. Conflict of Interest Disclosure
Dr. Raksha Joshi has no real or
apparent conflict of interest to
report
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3. A CMS DEMONSTRATION PROJECT
This presentation is the description of
A SUCCESSFUL CMS (CENTERS FOR MEDICARE
AND MEDICAID SERVICES)
DEMONSTRATION PROJECT
TO
ADD VALUE AND DECREASE COST
BY DECREASING
UNNECESSARY
EMERGENCY ROOM VISITS
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4. BACKGROUND
CARE IN THE EMERGENCY ROOM IS EXPENSIVE
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5. BACKGROUND
Access to primary care is affected by many factors
- Availability (hours of operation) of primary care office(s)
- Location
- Insurance coverage
- Cultural barriers
- Language barriers
- Health literacy
- Immigration status
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6. BACKGROUND
Federally Qualified Health Care Centers FQHCs
What are FQHCs
‘Safety-net providers of healthcare’
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7. BACKGROUND
FQHCs primary care providers
regulated by HRSA
community setting
Cannot decline care for any patient regardless of
- insurance or immigration status
- language or culture or ethnicity
- ability to pay
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8. INTRODUCTION
 Monmouth Family Health Center, FQHC since 2004.
 CMS grant
- to decrease non-emergency visits to the emergency room
- provide needed care in a timely fashion
- preferably the same day or within 24hours
 Charged with showing that we could sustain the program
after the grant duration (2 years) was completed
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9. FOCUS ON CORE CONSIDERATIONS
 CARE COORDINATION WOULD DECREASE COST
 METHODS THAT WORK FOR COORDINATION WITH A
HOSPITAL OR ANOTHER ORGANIZATION
 HOW CARE COORDINATION DECREASES COST AND
IMPROVES OUTCOMES
 MAKING THE SUCCESS SUSTAINABLE
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10. OBJECTIVE
To innovate care coordination methods between our
FQHC and our affiliate hospital
so that
inappropriate use of the emergency room is minimized
for non-emergency conditions
and
to make these innovations sustainable
while
improving health outcomes.
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11. METHOD CORE PRINCIPLES
 Use of THE SAME Health Information Technology
and Practice Management Systems by both the
hospital and FQHC to coordinate care
 Appointing personnel at both organizations to
send/receive patients who need care within 24
hours but are not 'emergencies'
 Coordinate and continue care and incorporate
these patients into preventive continued care to
improve health outcomes
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12. 12
CARE COORDINATION METHODS UTILIZED
'prime directive'
both partners (hospital and FQHC)
must have access to the same
data and practice management system
to facilitate communication.
Advanced Practice Nurses given access to
our practice management system

13. CARE COORDINATION METHODS UTILIZED –
PARTNER HOSPITAL ER
 Project Director
 Advance Practice Nurses
 Patient Care Assistants
 IT infrastructure
 Transportation
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14. 14
PATIENT THROUGHPUT PROCESS
Patient
Registration
ED
APN Assessment, Treatment,
Schedule Appt., Transportation
Evaluated
Appointment at
MFHC, Follow Up
Care, Patient
Education Case
Management
Follow Up /
Education
Primary Care
Team at MFHC
Engages Patient
Triage

15. CARE COORDINATION METHODS UTILIZED -FQHC
 Care Coordinator
 Primary Care Physician
 Patient Care Assistant
 Case Manager
 Data Analyst
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16. CARE COORDINATION METHODS UTILIZED
Each patient visit to the FQHC, care provider
- provided education and information
- reinforced by the case manager thereafter
- that the FQHC would be able to take care
of the patient on an 'urgent' basis and do
so quickly
- therefore reserve visiting the emergency
room only for real emergencies .
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17. CARE COORDINATION METHODS UTILIZED -
FQHC
a Case Manager
 tracked all patients sent to the FQHC
from the emergency room
 for the entire duration of the project
 contacted patients and facilitated
care coordination on both sides.
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18. PROJECT IMPACT ON CORE FOCUS POINTS
FOR FQHC
 ‘Express’ Primary Care
Services
 Access
 Primary Care Capacity
 Patient Education
 Outcome Evaluation
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19. RESULTS FOR FQHC
Overall, considering Adult Medicine, Pediatrics and
OBGYN
more than 82%
patients who were directed to the FQHC from their
first interaction in the Emergency room of our
partner hospital kept their appointments at the
FQHC
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20. RESULTS FOR FQHC
 In adult medicine alone, this
figure was 69%
 In ob-gyn, more than 98%
 In pediatrics, ~75%
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21. RESULTS FOR PARTNER HOSPITAL
Our partner hospital realized
a 20% increase in admissions rate
from patients who were deemed 'real
emergencies' and were further evaluated
in the emergency room,
meaning that
true emergencies remained in the
emergency room
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22. RESULTS FOR PARTNER HOSPITAL
Time from presentation
at emergency room
to admission to
a floor
reduced to less than 90 minutes
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23. RESULTS FOR THE FQHC SUSTAINED
AND CONTINUING RESULTS
Out of the 69% of the adult medicine
patients who first came to us via the
emergency room
49% have continued preventive and
continued care with the FQHC
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24. RESULTS FOR THE FQHC SUSTAINED AND
CONTINUING RESULTS
More than 90% of the OBGYN patients have
continued preventive and therapeutic care
with the FQHC
More than 70% of pediatric patients have
continued preventive and therapeutic care
with the FQHC
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25. RESULTS FOR THE FQHC
SUSTAINED AND CONTINUING RESULTS
 We have incorporated the 'open access' and
'emergency visit' slots in our daily FQHC
patient schedules, thus sustaining the
lessons learned from the project
 Patients have learned to call/directly come
in to the FQHC if they need care rather than
go to the ER
 The IT practice management sharing of
information continues between the hospital
and the FQHC
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26. CONCLUSION
Use of innovative means, use of
information technology to coordinate
care can reduce health care costs as
well as improve outcomes
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27. TAKE HOME MESSAGES
 Information sharing
 Care coordination
 Patient Education/Information
 Changes patient ‘culture’/mindset
 Increases preventive care utilization
 Improve outcomes
 Reduces cost
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28. THANK YOU
rjoshi@mfhcnj.org
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