Pediatric Emergency Department (ED) Case Management

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Pediatric Emergency Department (ED) Case
Management

• Ramona Waltman, RN, BSN, CCM
• Childrens Healthcare of Atlanta

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Why do patients use the ED?
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Childrens Healthcare of AtlantaWho Are We?

• 3 Hospitals
• 529 Beds
• 24, 572 admissions for 136,769 bed days
• 778,881 visits for 326,182 patients
• 17 Neighborhood Locations
• 5 Urgent Care Centers
• Marcus Autism Center
• 1 Primary Care Office

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Facts and Figures

• 200,000 yearly Emergency Department visits 550
  a day
• 100,843 Urgent Care Visits
• 46,551 Primary Care Physician Visits
• Serviced all Georgia counties, 43 states and
  countries around the world

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Childrens Healthcare of Atlanta is the

• One of largest Clinical Pediatric Provider in
  United States
• Largest Georgia Medicaid Provider
• 10th private employer in Georgia with 7800 staff
• Trauma Provider for pediatrics in Georgia
• Pediatric Rehabilitation Services
• Transplant Services
• AFLAC (Hematology/Oncology Services)
• Focus on Disease Management, Asthma and Diabetes

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Transplantation Performed at Childrens
Healthcare of Atlanta

• Liver, Kidney, Bone Marrow and Hearts
• 475 Kidneys
• 19 Livers, youngest and smallest patient weighing
  2 pounds
• Only pediatric center in Georgia for heart
  transplants, performed 3 transplants in a 24 hour
  period, one of few centers for ABO incompatible
  blood types
• 62 Bone Marrow Transplants and cures for 30
  patients with Sickle Cell Disease
• http//careforceconnection/Departments/TransplantS
  ervices/SitePages/Home.aspx

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Strong 4 Life Program

• Addressing childhood obesity jointly through
  efforts and partnering with community support and
  government agencies in Georgia
• 40 of Georgias children are obese, making
  Georgia 2nd in the country for obesity in
  children
• Childrens Healthcare of Atlanta employees have
  lost 35,459 pounds with fitness opportunities

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Why Childrens Healthcare of Atlanta is Crucial
to Georgia

• 28 of Georgias total population are children
• 52 of those children are enrolled in Medicaid or
  Georgias State Childrens Health Insurance
  Program (SCHIP) known as Peach Care
• 300,000 of Georgias children are uninsured
• Childrens Healthcare of Atlanta provided 90
  million in unreimbursed care in 2011

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Where to go?
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Georgia Medicaid

• Traditional Medicaid manages children who are
  eligible for supplemental security disability
  income and children in foster care
• The remainder of children enrolled in Georgias
  Medicaid program are enrolled in one of
  Medicaids care management organizations
• Wellcare
• Amerigroup
• Peachstate
• Another option is Peach Care, Georgias state
  child health insurance program. This option
  requires income eligibility and a monthly premium
  payment at a reduced rate for the families

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Why use the Emergency Department instead of
Primary Care Providers?

• Convenience
• Decreased wait times Victims of our Own Success
• Perception of Quality of Care
• ED access to diagnostic tests not available at
  Primary Care Provider
• Transportation barrier among families
• Often one car family (mother not driver) or a
  neighbors car available
• Financial Incentive
• Co-pays established for Primary Care Provider
  visits but not Emergency Department visits by
  Care Management Organization for Medicaid patients

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Georgia Medicaid

• Traditional Medicaid manages catastrophic
  illnesses and children in foster care
• Remainder of Children are enrolled in Medicaid
  care management organizations
• Wellcare
• Amerigroup
• Peachstate
• Nominal fee for coverage through Peach Care,
  which is Georgias state child health insurance
  program

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I am not feeling well, I vomiked twice! When
can I see you?
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Patient Barriers to Primary Care Access

• Perceived barriers when contacting Primary Care
  Providers (PCP)
• Access to PCPs nurse advice line
• If you feel you have an emergency hang up and
  call 911 or go to the nearest ED
• If you want to talk to a nurse or physician,
  this call will be subject to a 15 charge. Any
  calls to the CHOA nurse advice line will also be
  subject to a 15 charge. (Call center Services
  must charge fees due to Stark Laws while most
  insurance companies have a 24hr free nurse advice
  line) 1
• Limited availability same day and after hours
  appointments
• Compensation model from payers

1 Zaman Pediatrics After Hours Line 770-995-2946
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Pediatric ED Case ManagerPosition and Scope of
Work

• SR Case Manager position started Jan 1, 2012
• 1 FTE
• Staffed 8am-5pm 5 days/week (rotates between 2
  main campuses)
• 2500 ED CM referrals in the first 6 months

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Pediatrics ED Case ManagerKey Objectives

• Identify and reduce patient access barriers that
  result in non-emergent ED visits
• Target subset high utilizers
• Work directly with 3 Medicaid care management
  organizations (CMO) ED Case Managers to address
  payer specific barriers to primary care
• Support ED physicians to ensure adequate follow
  up for primary and specialty care
• Coordinate referrals to Patient Financial
  Services to determine financial eligibility for
  Medicaid
• Partner with ED physician and nursing staff to
  identify risk factors and patient specific
  conditions leading to 72hr ED returns
• Educate ED physicians on documentation of
  medically necessary admission criterias

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Connecting Patients and Payers

• 3 Medicaid Care Management Organizations in
  Georgia
• Daily list of ED visits sent to payers
• Initiated communication with hospital and CMOs
• Identify any actionable barriers to care that
  result in ED visits?
• Identified contact individuals at each payer
  source
• Target frequent ED users (6 visits/rolling
  calendar year)
• Identify actionable items representing barriers
  to access resulting in repeated ED visits
• Primary Care Physician assignment
• Assigned to a specialist instead of Primary Care
  Physician
• Primary Care Physician assigned is great distance
  from home
• Transportation barriers among patients and
  caregivers
• Lack of access to free or low cost medical and
  dental clinics for uninsured pediatric patients
• Provide community clinic lists

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Case Manager Identifies Barriers to Outpatient
Follow-Up

• Neurology services
• Reduction in physician providers on one campus
  from 7 to 4.5
• Neurology practices are non-providers in Medicaid
  and CMO plans for outpatient visits
• Orthopedic services
• Resolved out of pocket expenditures for fracture
  patients covered by one CMO payer
• Identifying barriers to follow-up care for
  uninsured, Medicaid pending and non-documented
  citizens

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Outpatient Follow-Up BarriersFinding a Solution

• 2 new seizure clinics operationalized
• Decreased time for new seizure follow up
  appointments from 2 months to 1 week
• Clinic physicians provides Neurology Services
  for hospitalized patients
• Partnered with Neuroscience Service Line
• First Time Non Febrile Seizure Pathway
• CM responsible for ED patient follow-up
• Referral s of patient to Seizure Clinic

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Primary Care Collaboration

• Initiated meeting with Medical Director and staff
  of Primary Care
• Established communication to identify Primary
  Care patients with high Emergency Department
  utilization
• Reported scheduling issues identified at Primary
  Care
• Identified Primary Care patients who could
  benefit from Primary Care follow-up post
  Emergency Department visits
• Reporting initiated to provide data for Primary
  Care patients treated in ED setting, being shared
  weekly to identify need for follow-up at Primary
  Care

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Uninsured PatientsReducing the Financial Impact

• Identified that uninsured patients (potentially
  eligible for assistance) receive limited follow
  up by our financial counseling team
• ED charges lt 3,000/visit frequently routinely
  not recovered
• Problem identified by ED Case Manager
• Established a process to identify and refer
  patients to financial counseling
• Single ED visit gt 3,000
• 6 emergency department visits in 12 month period
• Multiple siblings treated during same ED visit
• Out of state Medicaid patients who have moved to
  Georgia and need to transition/apply for Georgia
  Medicaid
• Currently tracking financial success with a goal
  of recouping 10 ED charges on patients eligible
  for coverage

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Future Goals for Tracking

• Are there trends of unscheduled ED return visits
  that can help identify high risk conditions and
  patients?
• Bronchiolitis
• Cellulitis
• Track unscheduled 72hr ED return visits
  categorized by
• Age of patient
• Payer source
• Diagnosis
• Reason for return to ED

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Admission Level of CareGetting it Right on the
Front End

• Increasing pressure to justify medical necessity
  for short inpatient admissions
• Insurance denials
• RAC Audits
• Significant difference in compensation between
  Inpatient vs. Observation Admissions
• Educate physicians on documentation of medical
  necessity criteria for DRGs with 1-2 days LOS
• Asthma
• Pneumonia
• Bronchiolitis
• Acute Gastroenteritis

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Pediatric ED Case ManagerTracking Performance

• Patients with high utilization of ED services
  referred to each CMO
• Document follow up from payer at 3 months
• Assess impact in reducing non-emergent ED visits
• Number of uninsured patients referred to
  financial counseling
• Reimbursement received through retroactive
  Medicaid billing
• Medical predictors by DRG for 72 ED return and
  subsequent readmission
• Bronchiolitis (age, 02 saturation)
• Cellulitis (age, presence of abscess, location
  infection, presence of fever)

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Meeting The Case Management Need

• Tracking patients who left without being seen
• Tracking patients who leave against medical
  advice
• Prevention of unnecessary ED visits
• Expanding the coverage to second campus

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Summary of Patients Receiving Benefits of ED
Case Management at Childrens Healthcare of
Atlanta

• Patients needing specialty care follow up
• Neurology
• Orthopedics
• Patients needing a better fit with their primary
  care physician
• Patients covered by Care Management Organizations
  (CMO) who need coordination of care
• Patients who are uninsured/non-documented and
  require continuation of care
• Patients covered by out of state Medicaid
  programs who reside in Georgia and need to
  transition to Georgia Medicaid