Avoidable Emergency Department (ED) Utilization

How to Identify and Manage a Main Cost Driver in Your ACO 

One of the important drivers of success in a value-based care (VBC) contract is managing avoidable utilization of emergency department (ED) and inpatient (IP) care.  When reviewing data inside of the Acclivity platform for the majority of my clients, it is not unusual to have the percentage of avoidable ED utilization as high as the low 60% range out of all ED visits. Analyzing the patterns of potentially avoidable ED use and determining the next actions are essential to success in a VBC contract.

Identifying Categories of Potentially Avoidable ED Utilization

When looking at the definitions of potentially avoidable ED use, the New York University algorithm is the gold standard and is incorporated into the Johns Hopkins ACG system inside of the Acclivity platform. The categories of potentially avoidable ED utilization are as follows:

• Non-emergent: The patient’s initial complaint, presenting symptoms, vital signs, medical history, and age indicated that immediate medical care was not required within 12 hours;
• Emergent/Primary Care Treatable: Based on information in the record, treatment was required within 12 hours, but care could have been provided effectively and safely in a primary care setting. The complaint did not require continuous observation, and no procedures were performed, or resources used that are not available in a primary care setting (e.g., CAT scan or certain lab tests);
• Emergent: ED Care Needed – Preventable/Avoidable – Emergency department care was required based on the complaint or procedures performed/resources used, but the emergent nature of the condition was potentially preventable/avoidable if timely and effective ambulatory care had been received during the episode of illness (e.g., the flare-ups of asthma, diabetes, congestive heart failure, etc.)

An ED visit that is in one of the potentially avoidable categories does not mean that the patient will not have an IP or observation (OBS) stay at the hospital.  That decision can be made based on the severity of the potentially avoidable situation is on presentation, but hospital census and other internal factors can be a significant push for IP or OBS admission

How To Avoid Unnecessary ED Utilization

When making an action plan, the first step is to analyze the data on potentially avoidable ED use. Determining the frequency that different patients, locations of care, and diagnoses are involved in the ED use is a first step. Are there specific days of the week or times or day for the ED use? Are there specific providers who have a pattern of potentially avoidable ED use? Are there patients who are routinely using the ED for potentially avoidable reasons, or specific diseases that are making up a large percentage of avoidable ED use? Develop a plan that is focused and not too broad for success – when the initial areas of concern are showing improvements, move to the next areas of concern.

The steps that can be taken depend on the identified areas of improvement based on the analysis of data. One intervention is reviewing the Care Management program at your practice or organization. Having extra touch points between the providers and the patients can provide for education on when to go to the ED, earlier identification of a pending change in medical needs, and identification of social determinants of health (SDOH) and health related social needs (HRSN) that can contribute to the potentially avoidable ED use. Care management involvement can also identify needs such as home health, caregivers, meal support or transportation issues that van impact the use of the ED. 

Other interventions for reducing potentially avoidable ED include using the alerts from a Health Information Exchange (HIE) such as is used to drive the Event Notification System (ENS) inside of Acclivity. A near real time call from the providers office can coordinate care with a visit to the provider instead of an IP admission for some non-emergent care needs. Having a provider available 24/7/365 can also reduce the need for a patient to go to an ED to have a provider assess their immediate needs as well as holding some early morning appointments available for late evening/overnight needs that can be managed in an office setting can also reduce ED and potential IP or OBS utilization. 

Evaluation of the impact of your interventions is essential. After implementing new procedures and/or programs, evaluate the Avoidable ED use – the Acclivity platform has a dashboard to give a detailed overview of Avoidable ED utilization – and conversion rates to IP or OBS status. When areas are showing improvement, review the next areas of focus to implement changes as well as continuing to review ongoing progress with the initial measures. The Johns Hopkins ACG system guidebook also shows ways to measure cost savings and preemptive actions that can impact this essential area of need for your VBC and ACO success.

For additional help or more information, set up a quick meeting.

Author:

Carol Javens, RN, BSN, CHPN | Account Manager, Acclivity Health Solutions