Medicaid and SCHIP Promising Practices

Name of Practice:

SoonerCare Emergency Room Utilization Project (ERU)
(OK0801)

Abstract:

The State of Oklahoma determined that patients who frequently visit emergency room (ER) facilities for non-emergency conditions do not receive optimal care, generate unnecessary costs for the Medicaid program, and are not adequately educated in how to utilize the health care system properly. The Emergency Room Utilization (ERU) Project identifies and contacts such individuals in order to ensure continuity of care through their medical home and provide care management for complex medical cases. The project furnishes Primary Care Providers (PCP) with information on patterns of inappropriate use and encourages PCPs to notify the State regarding members that may need intervention services. During 2006, SoonerCare reported 4,412 fewer ER visits, 32 fewer inpatient hospitalizations, and savings of approximately $1 million for members of the Intervention Group during the quarter following referral to Care Management. Continuity of care has improved and efficiencies have resulted from the use of the Medicaid Management Information System (MMIS) to track utilization by SoonerCare members participating in the ERU Project.

The Problem

The State of Oklahoma determined that patients who seek non-emergency care in ER facilities not only generate unnecessary costs for the Medicaid program but may also receive services that are inferior in quality to the care that they could have obtained in a more appropriate setting. The State found that non-emergency patients often encountered long waits for service as ER medical professionals tended to patients presenting true emergency situations. Because of their extreme workload demands, ER physicians were often unable to spend the time necessary to educate them on how to utilize the health care system properly.

Discussion of Approach

The ERU Project identifies and contacts SoonerCare members who exceed a predetermined threshold for emergency room utilization in order to redirect them to more appropriate sources of primary care. This Project was phased in beginning in January 2004. In the 2006 Legislative Session, the Oklahoma State House of Representatives passed HB 2842, which authorized a program to encourage the proper use of emergency rooms. This legislation funded additional staff for Member Services, Provider Services, Care Management, and Waiver Development.

To identify these individuals, the State's Quality Assurance/Improvement department first analyzed data from the MMIS on ER usage for SoonerCare traditional members with dates of service April through June 2004. A total of 669 members who made at least six ER visits that did not result in an inpatient admission and who remained eligible for the program were referred to the Care Management department. Over time, responsibility for this initiative has been transferred to the Member Services department and the visit threshold has been lowered from six to four ER visits per quarter, resulting in a doubling of the number of members to be called.

Beginning in 2006, registered nurses serving as exceptional needs coordinators attempted to contact members who exceeded the ER utilization threshold by telephone and letter to educate them on appropriate use of the Emergency Room. To best communicate with members who have low health literacy, the letters were written for a sixth grade comprehension level.

Member Services and Exceptional Needs coordinators assist these members by providing information about program benefits, identifying a PCP, and arranging specialty care for members with complex medical issues. Coordinators discuss appropriate ER utilization with the PCPs and encourage them to contact the State Medicaid agency when members need intervention services. Primary Care Providers are notified and furnished information on the admitting diagnoses when a member has made at least four ER visits. Members who have made at least 10 ER visits over three consecutive quarters are targeted for more intensive interventions.

Results

During 2006, SoonerCare reported 4,412 fewer ER visits, 32 fewer inpatient hospitalizations, and savings of approximately $1 million for members of the Intervention Group during the quarter following referral to Care Management. If the trending of these clients had spanned the entire year, it is likely that the actual cumulative decrease in ER visits would have proven to be higher.

Educated, properly aligned members have experienced greater continuity of care by utilizing their Primary Care Providers instead of the Emergency Room for routine care.

Using the MMIS to provide quarterly updates of data for the members targeted for intervention has reduced the number of staff hours required for completion of interventions, data analysis, and reporting.

Further Information

Contact:
Rebecca Pasternik-Ikard
Oklahoma Health Care Authority (OHCA)
4545 N. Lincoln Boulevard
Suite 124
Oklahoma City, OK 73105
(405) 522-7208
e-mail: becky.pasternik-ikard@okhca.org

This Profile has been posted to the CMS Medicaid/SCHIP Quality website for informational purposes only and does not convey CMS endorsement of the practice itself. The descriptive information supplied and the results reported in this Profile have been supplied by sources familiar with the practice but have not been independently validated by CMS.

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