Collective action to the rescue
How to address this intractable issue? Here’s what NEVHC staff did know: They had a continuity of care problem. They often found out about patient emergency department visits in an ad hoc fashion—frequently well after the fact. Parents or guardians might call to schedule a follow-up visit, or report the ED visit at a subsequent appointment. Sometimes the asthma team received what’s known as a Continuity of Care Document (CCD), which is sent to primary care clinics through the Health Information Exchange (HIE) directly to a patient’s chart with or without notification.
This inconsistent tracking “system”—from a variety of sources of mixed reliability—meant that care coordinators were often not able to provide timely, appropriate, and complete follow-up care to help a patient manage asthma and attempt to avoid preventable future emergency room use. From a safety net clinic perspective, it was frustrating, worrisome, and a poor use of limited resources.
Surely a technology solution could help address this matter?
Bingo. NEVHC learned about a healthcare information sharing network Collective Medical, which provides a comprehensive way to receive electronic notifications when an assigned managed care member presents in an emergency department or hospital. The Utah-based patient data information platform is designed to help care teams collaborate to support the most vulnerable patients, those whose needs can’t be met in any single care setting. It offers services designed to address readmissions, opioid addiction, behavioral health, workplace safety, and other concerns. Its ED utilization program is constructed to reduce unnecessary ED visits by addressing their cause.
NEVHC was introduced to Collective Medical through Health Care LA – IPA, which provided funding for the project. Health Care LA – IPA is a not-for-profit network of Federally Qualified Health Centers (FQHC) and community health centers serving vulnerable patient communities in Los Angeles County since 1991. It provides expertise and resources to its more than 40 health center members.
NEVHC is also a member of CCI’s Technology Hub. CCI, with support from the California Health Care Foundation, partners with safety net clinics such as NEVHC to vet, pilot, evaluate, and integrate innovative digital health solutions designed to benefit underserved communities. For instance, NEVHC has worked with CCI in the recent past on piloting a digital platform for respiratory health management for asthma patients, and introduced a free, online social services referral platform for patients, among other tech innovations. NEVHC was also one of seven clinics chosen to be part of CCI’s ROOTS program which looked at social determinants of health; the health center focused on a digital tool for screening patients for food insecurity.
NEVHC staff worked directly with Collective Medical to identify specific criteria for asthma or asthma-like symptoms documented as the chief complaint in an emergency room visit and set up a process to generate electronic notifications to designated staff via email—in this case a health educator and the director of quality and health education—when a patient presented in the ER. Rosen wanted to be in the loop to get a real time sense of the volume of notifications, she says, and to oversee the project.
As part of NEVHC’s workflow, the health educator responded to each alert, reviewed the patient’s record in NextGen, the health center’s electronic health records (EHR), and, based on previously established guidelines, sent an alert through the system’s EHR to either the provider or asthma care coordinator, who followed up with the patient as needed.
Reports from these alerts, which were manually generated, included data such as the total number of pediatric notifications, number of assigned members who had never been seen at NEVHC, number of repeat patients, number of patients with or without an asthma diagnosis, and the number of provider test actions created. Rosen says the system generated a lot more alerts than expected, and many of them were for patients without an asthma diagnosis.
During this pilot program, which ran between December 18, 2018 and August 8, 2019, NEVHC received 1,046 emergency department notifications. Of those, 172 were pediatric patients with an asthma diagnosis and 661 were pediatric patients who did not have a diagnosis for the disease. The number of repeat pediatric patients in the mix totaled 106, and 32 of the patients had never been seen at NEVHC. The alerts generated 771 provider test actions.
The data is reviewed and analyzed each month by NEVHC’s asthma quality improvement committee. Initially, Rosen recalls, there was a lot of discussion about the number of alerts generated and the subsequent number of provider test actions. There was a lot of variability in the number of alerts—between flu season and non-flu season, for example.
During the height of the 2018-2019 flu season provider alerts jumped from a baseline of one to three alerts a day to around 13 a day, which proved taxing for staff and providers. While increasing their workload, it’s also part of their job description to improve patients’ ability to manage their asthma symptoms, says Rosen. That said, since COVID-19, those alert numbers have dropped dramatically. “That tells me two things,” says Rosen: “There’s a lot of inappropriate use of the ED — and, for those patients who may really need to use it, they may be too scared to go.”
Expanding Collective Medical to other cohorts
Across the board, NEVHC viewed the digital tracking system as a valuable addition to their online arsenal.
Jasmine Uribe, NEVHC asthma coordinator
“Collective Medical is a useful tool to gather real-time information on patients who are being seen in the emergency department,” says Jasmine Uribe, a health educator and asthma coordinator at NEVHC. “We learn about patients who have never been seen by their assigned PCP or who need to schedule a follow-up visit with their PCP. And we are able to provide education, support, and connect these patients back to primary care and hopefully reduce ED visits in the future.”
The NEVHC team is keen to find ways to prevent unnecessary frequent flyers to the ED. “Receiving notifications in real time that one of our assigned patients is in the Emergency Department or has been admitted to the hospital can potentially reduce ED utilization, reduce readmissions, support transitions in care, and improve patient outcomes,” says Rosen.
Physicians see the merit in Collective Medical too. “The utility of the alerts were that we could assess the patients and determine the appropriate timing for follow up visits,” says Gina Johnson, medical director of pediatrics at NEVHC. “We have also been able to make full use of our asthma educators’ case management and health education skills for prevention of future inappropriate ED visits and indications for visits with their primary care providers.”
There were some unexpected benefits of the program, notes Rosen. “Occasionally we found a more accurate telephone number provided in the ED, which helps support follow-up,” she says. “We were also surprised by how often our patients frequent the ED. And we found patients assigned to NEVHC but who had never been seen at our clinics. This provides us with an excellent opportunity to try to engage the patient and establish care with a primary care provider.”
And, of course, there are some additional costs to adding something new to staff workloads. “It also adds work without direct reimbursement. Personnel resources are needed to respond to notifications, staff must be identified to follow-up on the notifications, and providers must evaluate next steps for the patients,” Rosen explains.
The scope of the project did not include funding to evaluate the program, which is unfortunate, says Rosen, because it makes it challenging to get a handle on how useful the tool actually is at keeping patients out of the ED unnecessarily, among other measures. In an ideal world, she adds, the pilot would have been conducted alongside another health center, for comparison purposes.
That said, the Collective Medical platform offers FQHCs “enormous opportunities, says Rosen.
Identify the right staff. For the Collective Medical pilot to run smoothly, it was important to make sure the appropriate team members were designated to receive alerts—somebody who could add to their current work load—and be able to provide follow-up.
Consider clinical priorities.Which patients might most benefit from this kind of information sharing system? Start there to pilot this program and track whether or not it leads to improved clinical outcomes.
Create an evaluation plan. The goal here is to optimize patient outcomes and reduce inappropriate ED use, so make sure you include an effective way to monitor if these goals are actually being met as part of the pilot. While a control group may not be clinically defensible in these kinds of situations, a comparison study may help tease out trends in data, such as whether the pilot decreased emergency department use.
The intervention works from a functional end, in that NEVHC is now in the loop when its patients land in the ED. But the clinic would welcome additional resources to evaluate the effectiveness of the intervention. Has there been a decrease in emergency department visits for pediatric patients with asthma—as well as pediatric patients without an asthma diagnosis?
There are, of course, many ways to follow up with these patients and support their care. For instance, with pediatric asthma patients who are high frequent users of the emergency department—for the purposes of this project that was considered 12 ED visits in a year—care teams identify resources and interventions that may help resolve these acute incidents without the need for an ED visit in the future.
NEVHC saw enough value in the new approach to roll out the program to other patient populations. The center is currently using Collective Medical for its diabetes patients who land in the ED, as well as patients who frequent the emergency department and are eligible for Health Homes, a Medicaid program for patients with multiple, chronic conditions. The program is designed so providers can integrate and coordinate all primary, acute, behavioral health, and long term services and supports a “whole person” approach to health care.
NEVHC also plans to prioritize higher risk adult Medi-Cal managed care members who have never been seen in the clinic setting but are regular emergency department visitors or frequently hospitalized for outreach efforts.
“The solution works and this technology provides enormous potential to decrease ED utilization, reduce hospital readmissions, and improve outcomes for our patients,” says Rosen. “The challenge is to align incentives to support the technology and the resources needed. As we strategize about how to expand this work, we have identified many opportunities to reach out to other populations—such as patients with diabetes, those who are eligible for Health Homes, and assigned members who have never been seen at NEVHC. This will help us connect these patients to primary care.”
“We think they will be more receptive to routine care following an ED visit — oftentimes patients don’t feel they need primary care services or that they have health issues,” Rosen concludes. “They’re a bit more inclined to come and see a provider and establish care when we follow up after an alert. It’s a great way to reach patients who could benefit from our services.”