Transcript DSHS Presentation - Washington State Hospital Association

Medicaid Quality Incentive: Plan for
Reducing Preventable Emergency
Room Visits
Department of Social and Health Services
Health & Recovery Services Administration
Thuy Hua-ly
Jeff Thompson
Vazaskia Caldwell
Beverly Court
April 19, 2011
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Medicaid Quality Incentive
Policy Intent
• Engage hospitals in quality improvement
– “Float all boats” rather than rewarding highest
– Pairing monetary incentive with collaborative
learning and “safe table” forums
– Systems approach (include community
partners)
• Focus on Medicaid managed care
population
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Incentive Structure
Five Measures
– Healthcare Worker Flu Immunization
– Patient Discharge Information
– Elective Delivery Prior to 39 Weeks
– Reducing Preventable Emergency Room Visits
– Patients Discharged on Multiple Antipsychotic
Medications with Appropriate Justification
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Incentive Scoring
• Each measure scores 0, 3, 5 or 10 points
• Hospital qualifies for 1% rate increase if
has average score of 5 or higher
• Public acknowledgement of hospitals
with average of 10 points
• No partial or pro-rated incentive
payments allowed by the enabling
legislation.
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Reducing Preventable Emergency
Dept Visits Measure
• First year – a comprehensive hospital plan
• Plan has 5 sections
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Community Partnerships
Data Reporting
Strategic Plan for Prevention of Visit
Emergency Room Visit Follow-up
Continuing Education
• Points
– 3 sections – 3 points
– 4 sections – 5 points
– 5 sections – 10 points
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Section 1: Community
Partnerships
Documentation that infrastructure is in place
which includes relevant community partners
• Name and addresses of Emergency
Departments, both on and off campus
• Names and positions of hospital staff and
community partners in workgroup.
• Minutes of workgroup meetings with future
meeting dates. Workgroup with relevant
community partners must have met at least
once prior to plan approval.
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Section 2: Data Reporting
Evidence of collection and analysis of data
upon which to create an informed plan.
• Data report which identifies preventable
ER visits using standard methodology such
as MediCal groupings, New York University
groupings, or own version.
• Report should identify visits for Medicaid
managed care clients by Healthy Options
plan, at a minimum.
• Identification of the top five reasons for
potentially avoidable ER visits.
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Section 3: Strategic Plan for
Prevention of Visits
Creation of strategies to prevent visits
• Develop at least two strategies with
community partners to help patients learn
in advance of arriving in the ER how to
access care in less expensive location. Must
include full work plan description, who,
what, where, when, how.
• Refrain from explicitly soliciting primary
care visits to the hospital’s ER in marketing
materials such as billboards, radio, scripts,
etc.
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Section 4: ER Visit Follow-Up
Create strategies addressing patients who have arrived
in the Emergency Department
• Minimum 2 strategies with community partners
addressing patients who have arrived in the
Emergency Department but could be seen in less
expensive location.
• Describe method of identifying patients and
notifying managed care organizations or their
designated primary care clinics of the client’s use of
the ER in a timely way, either in-place or in process
of implementation.
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Section 5: Participation in
Continuing Education
• Evidence of at least one hospital team
member attending educational
programs by the state, such as web
conference for CEOs, ER Directors and
key administrators or an in-person
meeting on best practices.
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Submission Process
• Use Plan Template or Word document
with similar format
• No more than 15 pages
• Send via e-mail to
[email protected]
• Hospital plans will be posted for the
public via Medicaid’s news website at
http://hrsa.dshs.wa.gov/News/index.htm
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Emergency Department
Alternative Care Grant
• Washington State DSHS/MPA
– Funded by CMS
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1 of 20 State Successful Bidders
2 years of grant funding
$1,963,581 grant
To establish Alternative Non-Emergency
Service Providers or Networks of Such
Providers through grants
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COLLABORATIVE PARTNERS
• Washington State Hospital Association
(WSHA)
• Washington Association of Community
and Migrant Health Centers (WACMHC)
• DSHS Research and Data Analysis
Division
• Dr. Fred Connell, University of
Washington
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4 PILOTS & PARTNERS
• Community Health Association of
Spokane
– Partner: Holy Family Hospital
• Lourdes Health Network
– Partners: Miramar Clinic and TriCities
Community Clinic
• Health Point Community Health Clinic
– Auburn Regional Medical Center
• Interfaith Community Health Clinic
– Peace Health St. Josephs Hospital
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INTENT OF THE PILOT
• Develop and Test a variety of initiatives
aimed at reducing inappropriate emergency
department use among Medicaid enrollees
(ME)
• Connect ME with medical homes and case
management services
• Educate ME about the appropriate use of
emergency departments and primary care
• Improve access to primary care
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PILOT STRATEGIES
• 3 Required Strategies:
– 24‐hour access to professional services by
providing a nurse‐triage line in project
communities,
– Improve the ability of community health clinics
(CHCs) to be effective Medical Homes and
alternate emergency care providers, and
– Create a case management system that is
integrated with the nurse‐triage system to
follow‐up on emergency department visits and
connect patients with other needed services.
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EFFECTIVE PRACTICES
 Direct communication between partner sites
 Sharing of information to ensure high quality
medical care
 Well-defined and proactive referral process
 Pain management program
 DSHS Patient Review and Coordination
 Care coordination
 Patient Advocate
 Clinic/ER Liaison
 Community-wide education
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PILOT STATUS
• Pilot ended on April 14, 2011
• DSHS Research and Data Analysis in
collaboration with UW will be producing
a pilot evaluation in July 2011
• DSHS Medicaid Purchasing
Administration in partnership with
WACMHC will be producing a final
report on pilots in July 2011
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More Information
Thuy Hua-ly e-mail
[email protected]
Washington State Hospital Association
website
http://www.wsha.org/0382.cfm
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