Here is a letter I wrote to Aledade Partner Practices prior to the holidays. – Farzad
Farzad Mostashari, CEO
Dear Aledade ACO Partner Practices,
Last winter, my mom, who is generally healthy, was home in Boston alone when she got hit by an acute gastroenteritis – likely norovirus. When I called her she was in bed – vomiting, unable to keep anything down, feeling weak and complaining of severe leg cramps. She was clearly unable to get to the pharmacy by herself, and I had that dreaded feeling – of being 400 miles away and powerless to help. I could see the whole sequence unfolding. The ambulance crew carrying her down the stairs. The overnight sleepless stay in the ED for a liter of fluid. God forbid they should decide she’s not safe to go home by herself and admit her. Fortunately, I was able to get her an appointment at her primary care practice for that afternoon, and a family friend to take her soup and hold her arm. It all ended well. She avoided a horrendous experience, and Medicare avoided several thousand dollars in unnecessary cost.
This incident drove home to me how important the work is that we are doing together.
We are about to enter 2015, and the beginning of our “performance period.” We will be working with you over the next three years on a whole host of improvement efforts, from better referral management and medication adherence to post-acute care and social supports. But let’s be clear on what our #1 priority is for the new year: reducing unnecessary emergency department visits and hospital admissions.
As always, let’s start with the patient. For most elderly patients, being seen in an emergency department is an uncomfortable ordeal, and any hospital admission carries with it significant risks and hazards. Fully one-in-three Medicare patients suffer a health care-acquired condition during their admission – from infections to falls, medication mishaps, and delirium. Many never regain their former level of functioning. Elderly patients without the means to purchase supplemental insurance can be hit with hundreds to thousands of dollars in unexpected costs.
We never want to stint on needed care, and we won’t, because many, if not most of these visits are avoidable. As our Delaware Medical Director, Dr. Horatio “Rash” Jones (who moonlights in emergency departments in addition to his primary care practice) recounted at our December ACO board meeting, 90 percent of the patients he sees could have been taken care of in a lower-acuity setting.
Now we don’t need to reduce these admissions by 90 percent! However, if we can just take out one of every 10 ED visits and admissions, our ACO would share in savings. Each unnecessary admission you prevent is worth on average $3,000 to your practice. How many 99213 visits is that?
So what works in reducing these harmful and expensive visits and admissions?
1) Let patients know that you want to hear from them before they go the ED. The number one reason patients don’t call their PCP is “I didn’t want to bother the doctor”. Let them know that you want to hear from them, and that you mean it.
2) Make sure that your after-hours and weekend system works for the patient.
Do patients know what number to call? What does the answering service say? How hard is it to speak to a doctor? We will explore together whether there are weekend and after-hours options other than the ED for patients who don’t need to be there.
3) Make it easy for them to get care in the right place.
During business hours, that would be your office. Dr. William Funk of Newark, DE pioneered the use of same-day open scheduling for sick visits long before NCQA made it a PCMH requirement. It works. Other pioneering practices have implemented services like IV fluids and nebulizer treatments to help patients who need a little extra care right then and there, instead of having to go to the ED.
4) Communicate with the ED docs.
One out of every seven admissions is due to missing information. Is that right bundle branch block present on an old EKG? Did Mr. Williams have a clean cath report last fall? Was there a full workup for that isolated hematuria done already? Does the patient have a pattern of narcotic-seeking behavior?
5) Assure the ED docs of timely follow up.
There are many common conditions with high variability in whether they get admitted to the hospital or not: skin infections, UTIs, COPD, mood disorders, non-specific chest pain. The deciding factor is often whether the ED physician is confident that there will be outpatient follow up. Can you see the patient in the office tomorrow to check on that cellulitis (which is actually venostasis)?
Over the next month, we will be working with you to identify where there are opportunities to improve your current procedures, and how we can help in implementing those changes. I am sure that in your daily work and experience you will find many more valuable insights for how we can prevent unnecessary ED visits and hospital admissions. We are very much looking forward to hearing about the ideas from you and testing and spreading them. And because of the work you do, there will be a son or daughter somewhere who will rest easier that their parent, miles away, won’t end up in the ED, but will be cared for.
Yours in health,