Simply defined, PHM is a proactive approach that ensures a group of patients gets the right care, at the right time, in the right place. The goal is improved value (meaning better care at lower cost) as well as a more seamless experience for patients.
Historically, emergency providers have rarely engaged in PHM activities like preventive care or disease management. Today, when they do participate in PHM, it's usually with an eye toward promoting appropriate utilization (i.e., reducing non-emergent visits, managing "frequent fliers").
Some EDs, including two in my region, are assuming a broader role. Given that the average inpatient stay now tops $10,000, it’s important for quality-minded health systems to reduce preventable admissions. To combat this, these EDs now provide high-risk patients with more comprehensive workups, treatments and care coordination.
In some cases, this means a patient who normally would have been admitted can be safely discharged with appropriate follow-up in place. When these patients are admitted, the extra attention provided in the ED can help reduce inpatient length of stay.
In this post, I'll describe an innovative PHM process followed at two Vituity EDs, plus some considerations for implementation.
New Ways to Flow
Vituity staffs two hospital EDs in my region that are part of the same accountable care organization. Like most ACO providers, the hospitals share risk for the patients they manage, which incentivizes quality, proactivity and efficiency. This particular ACO has been quite successful in reducing medical costs per member while delivering excellent outcomes for patients.
Earlier this year, the ACO leadership asked Vituity for help in managing some of its high-risk patients and those who are frequent ED utilizers. Their hope was to safely "de-escalate" these patients; in other words, to prevent an unnecessary admission.
Vituity emergency physicians worked with the ACO's chief medical officer to co-design a new flow process especially for the high-risk patients. They focused on three common scenarios:
1. Patient can be safely discharged if appropriate follow-up is in place. For lower-acuity visits, the ED physician works with case management to arrange follow-up with a primary care provider (PCP) or specialist. (This process is facilitated by the ACO, which provides a full continuum of care.) PCPs are expected to provide same-day appointments to patients referred before noon and next-day appointments to anyone referred later.
2. Patient requires eyes-on consultation to determine disposition.
The ED physician contacts the appropriate consultant, who comes to the ED within 60 minutes to help evaluate the patient and determine appropriate disposition. As needed, the consultant can recommend further testing in the ED or observation care.
3. Patient requiring consultation presents after-hours. The emergency physician contacts a designated specialist by phone to consult about further testing and disposition. Next-day follow-up is scheduled for all discharged patients.
The new process is currently being piloted with a group of high-risk patients who have chronic cardiac conditions. The hospitals' cardiologists and their offices are partnering with the emergency physicians to manage this population. Additional specialties will be added once the process is fully tested and implemented.
The ACO has an ambitious long-term PHM plan in which emergency and primary care physicians will eventually work together to deliver preventive care and manage chronic conditions. This approach will address the root causes of frequent ED utilization, including chronic disease exacerbation and undiagnosed medical conditions.
In the future, when a patient in the target population presents to the ED, the emergency physician will consult a centralized call center to see if the person is due for vaccinations, screening tests or other preventive care. If, for example, the patient is due for a pneumonia vaccine, the emergency physician would either administer it or arrange a next-day appointment with the primary care provider.
Eventually, the program will also extend continuity of care from the ED into the community. Patients with chronic conditions will participate in telemonitoring, with results available to both the PCP and emergency physician (should the patient arrive in the ED). An ED clinical pharmacist and assistant will follow up with discharged patients to provide medication education and reconciliation. We also plan to add a home health nurse who will make regular visits to participating patients, reducing the need for ED visits and admissions.
In order for an ED to participate in PHM to its fullest potential, both the department and its parent hospital need to take a big-picture view of value.
In measuring ED care quality, healthcare regulators focus heavily on throughput. However, giving complex patients the extra care they need to manage their health necessarily requires significant investments of time.
Arguably, this temporary dip in efficiency will be more than offset if an inpatient admission can be shortened or avoided. However, the process may feel uncomfortable for staff members who have been conditioned to strive for maximum efficiency. As with any major culture change, good leadership is essential to gain buy-in.
It may also be helpful to put the numbers in perspective. PHM is designed to be practiced with a targeted group of patients. At our two hospitals, that currently works out to one or two patient encounters per shift. So far, it's been quite manageable and hasn't required additional staffing.
Finally, it's important to remember the value of preventing an unnecessary hospital admission. Inpatient stays are financially costly for both the system and patients. They create hassles, confusion and emotional strain. By going the extra mile in the ED, we help ensure the very best care for some of the most vulnerable people in our communities.