Patient-Specific Care Plans Cut Costs, Preventable ED Visits

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A pilot quality program at Regions Hospital in St. Paul, Minn., that developed care plans reduced emergency department visits and admissions by 65 percent among frequent ED patients and generated an estimated $511,000 in cost savings. These results were calculated by comparing data from two months prior to care plan implementation to two months after implementation.

Regions Hospital launched the initiative in August 2011 in partnership with its affiliate, Bloomington, Minn.-based HealthPartners, to address frequent ED visits by certain patients. Less than 1 percent of patients are responsible for nearly 22 percent of healthcare spending, according to the Agency for Healthcare Research and Quality. Much of these costs come from unnecessary and preventable ED visits and admissions.

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The pilot program was led by Rick Hilger, MD, a HealthPartners hospitalist at Regions Hospital, and created care plans for 27 patients identified as high-risk for repeat ED visits. The initiative's success has led the hospital to look into how to modify care plans over time to meet patients' changing needs and how to expand the program to other populations. Rachel Dahms, MD, an emergency physician who helped develop and implement the program, explains how care plans can improve care and reduce costs.

Identifying and managing risks
Regions Hospital identified risk factors for patients with frequent ED visits. They found patients who use narcotics and other controlled substances; patients with psychiatric disorders such as personality disorders, anxiety and schizophrenia; and patients who do not comply with medical treatment recommendations are more likely to visit the ED frequently and less likely to see a primary care physician.

To improve care coordination and continuity, a team of nurses, social workers, physicians and other staff at Regions Hospital created care plans that set expectations for care and provide healthcare resources. Physicians discus the care plans, which can be personalized for each individual patient's needs, with patients and incorporate them into electronic medical records so they are available to care providers throughout HealthPartners' five hospitals and 25 medical clinics.

Care plans help patients connect to primary care and specialty physicians and set expectations that patients follow up with physicians regularly. For example, Dr. Dahms says one patient alternated appointments each week between a primary care physician and endocrinologist to maintain health and prevent needing to visit the ED. Depending on the patient, some care plans may restrict patients' ability to receive narcotics in the ED and expect patients to be compliant with the therapist if admitted for care.

The care plans establish guidelines for care that the health system supports with its resources of physicians, case managers and other providers. "The system was built around [the care plans] to support them," Dr. Dahms says. "It was guidance to get patients psychiatric help, to help with chemical dependency issues and sometimes to help get [them] to a clinic — whether showing them the right bus line or helping make arrangements so the patient wasn't forced to do that on their own."

Encouraging adherence
One of the challenges of implementing the care plans is ensuring patients' adherence to the plans, as many of the expectations — such as not receiving narcotics in the ED — were disagreeable to patients. "They're not always things patients agreed to," Dr. Dahms says. "That's when we fell back on our conversation that 'That's what we need to provide you to get you healthy. If you come to the ER, we're not going to give you narcotics, but here are some alternatives.'" Embedding the plans in patients' EMRs helped adherence because all of a patient's providers were on the same page about what was best for the patient's care.

Another challenge is enforcing adherence among providers. "It's hard to hear someone say [he or she] is in excruciating pain and not give narcotics," Dr. Dahms says. Physician and administration buy-in is critical to ensuring consistency in high-risk patients' care plans. Speaking face-to-face with stakeholders and developing physician champions can help gain buy-in and establish this consistency. Partnering with primary physicians is especially important because they will need to commit the time, energy and resources to care for high-risk patients, perhaps scheduling weekly appointments to ensure continuity of care. Dr. Dahms suggests that if physicians do not follow a patient's care plan, to ask why and to ask what tools can be provided next time so the physician has the understanding and willingness to follow through on plans to prevent unnecessary ED visits and hospitalizations.

Care plans are not meant to punish patients or restrict physicians' choices in care, but are designed to broaden patients' options and provide best practices to prevent unnecessary ED visits. "We were trying to give patients a sense of control about how they could maintain their health," Dr. Dahms says. "Focus on patient safety, the fact that continuity is important, that we can coordinate care and that delivering better care makes a difference; it keeps us from being something negative and penalizing and [transforms us] into something positive and supporting," she says.

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