Maximizing Efficiency and
Productivity in Your Rural ER
Bruce Penner, RN David D. Luehr, MD
Can we afford to continue as we are?
What if your ER had to pay for itself?
What if you were rated on patient
outcomes?
•Improving Patient Experience
•(quality and satisfaction)
•Improving Population Health
•Reducing Cost
Clinics
Hospitals
(ER, Out Pt, In Pt)
The Patient’s Perspective
Hospitals
(ER, Out Pt,
In Pt)
Emergency
Dept.
Reduce Cost
Improve Outcomes/Quality
Justify Cost with Improved
Outcomes/Quality
Clinics
ER
Clinics
ER
Clinical Alignment
Clinical Integration:
Collaboration among different health
care providers and sites to ensure
higher quality, better coordinated and
more efficient services for patients.
Clinical Alignment:
A patient centered process that
addresses acute and chronic illness
across a care continuum. It recognizes
and puts the true needs of the patient
first and works with others in the care
continuum to meet those needs by
encouraging the right care be given in
http://www.debt.org/medical/emergency-room-urgent-care-costs/
• 136.1 million ER visits in 2012 • 20 million arrived by ambulance
• 116 million arrived by other means
http://www.debt.org/medical/emergency-room-urgent-care-costs/
CDC: Top Three Reasons for Visits (2007)
• Superficial injuries
• Contusions, sprains and strains • Upper respiratory infections
http://health.howstuffworks.com/medicine/10-common-reasons-for-er-visit.htm
Top Ten Reasons for Visits
Discovery Health
•Chest pain/SOB •Belly pain
•Toothache
•Sprains, strains, fractures •Colds (URI)
•Cuts, bruises •Back pain
•Skin problems, rashes, infections •Foreign bodies
Depending on the severity of the pain or condition, 9 out 10 of the top medical
reasons people go to an ER for are
routinely addressed in the primary care setting.
If we are doing that much “primary
care” in the ER are we doing that
http://www.debt.org/medical/emergency-room-urgent-care-costs/
Who’s Paying the Bill?
•Private insurance: 54 percent
•Medicare: about 38 percent
•Medicaid: about 33 percent
•Uninsured patients: 35 percent
46% is self pay or government
paid
“Pulling all that data together, researchers found that the average charge for an
emergency room trip…came out to $1,233, which is 40 percent higher than the average American rent ...$871 per month.”
Current Payment Reforms
• Coming from all payers
• Total Cost of Care (TCOC)
• ACO
• Risk Sharing: up and down
All are focused on reducing cost in all
areas while improving quality of care.
http://www.mainstreetmedica.com/compare-care-options#costs
$89 $97 $345 $0 $50 $100 $150 $200 $250 $300 $350 $400 Primary Care Clinic
Urgent Care Emergency Department
$89 $127 $595 $0 $100 $200 $300 $400 $500 $600 $700 Primary Care Clinic
Urgent Care Emergency Department
$85 $114 $665 $0 $100 $200 $300 $400 $500 $600 $700 Primary Care Clinic
Urgent Care Emergency Department
$81 $110 $400 $0 $50 $100 $150 $200 $250 $300 $350 $400 $450 Primary Care Clinic
Urgent Care Emergency Department
$98 $94 $525 $0 $100 $200 $300 $400 $500 $600 Primary Care Clinic
Urgent Care Emergency Department
$76 $102 $370 $0 $50 $100 $150 $200 $250 $300 $350 $400 Primary Care Clinic
Urgent Care Emergency Department
$85 $112 $617 $0 $100 $200 $300 $400 $500 $600 $700 Primary Care Clinic
Urgent Care Emergency Department
$93 $123 $531 $0 $100 $200 $300 $400 $500 $600 Primary Care Clinic
Urgent Care Emergency Department
$83 $111 $486 $0 $100 $200 $300 $400 $500 $600 Primary Care Clinic
Urgent Care Emergency Department
Cost Disparity
Urgent Care
21% more than PCC
ER Care
How much does care
cost in an ER?
How much does it cost
an ER to give care?
Reduce Cost
Improve Outcomes/Quality
Justify Cost with Improved
Outcomes/Quality
Quality Evidence Based Medicine
and
Excellent Customer Service
Never Goes Out of Style!
• Clinical Quality – clinical care that is
measurably superior by recognized standards. • Service Excellence - meeting the needs and
fulfilling the expectations of patients and staff. • Operational Efficiency – doing both of the
above efficiently without time/resource waste.
0 5 10 15 20 25 30 35 40 45 99281 99282 99283 99284 99285 CC Actual % MN Ave %
Actual Revenue $2,659,810 Average Revenue $4,441,23 Lost Revenue
$1,781,429
Revenue Differential
Key Attributes of an Efficient ED
•Be Decisive
•Stay Focused
•Make use of any down time
•Take charts out of order
•D/C first
Patients should leave the ED
with a primary care
appointment and get a f/u call
to confirm it.
Post visit calls reduce the likelihood of
bounce backs and readmissions!
Patient satisfaction is doubled
with follow up calls. 58% -> 95%)
ER/Primary Care
Clinical Alignment
Building a Care
Continuum
Dx. of HTN Start Med Refer to PCC Make Appt.
Identify and Treat Chronic Illness
in ER
Example: Patient has been seen
multiple times in ED with elevated BP each time.
•Use ACT/C-ACT (asthma control test)
•Can be done by nurse
• Asthma Action Plan completed • Reinforce need for PCC follow up • Make appointment if possible
Identify and Treat Chronic Illness
in ER
Example: Patient presents with asthma exacerbation.
Treat ED visit as a consult, not just
an “emergency.”
• Consult notes sent to primary care physician
• Clear and concise communication between physicians
•Pre-developed tools/forms/methods
Use common terms in ER
and clinic to improve
patient
Use standard patient
education material in ER
Use motivational
interviewing technique in
ER.
• Open ended questions • Affirmations
• Reflections • Summarizing
Use motivational
interviewing technique in
ER.
Easily learned and easily usable by all ER staff.
“You’ve heard from many healthcare providers that you should quit smoking.”
“How do you think you can motivate yourself to change?”
Use motivational
interviewing technique in
ER.
Easily learned and easily usable by all ER staff.
“You’ve quit for two days!.”
“Think of all you’ve learned about succeeding at that attempt.”
Recognize and utilize
non-physician staff up to
their full level of license.
Nurses as team members.
Maximize their responsibility and
role.
Collaborate (ER, primary care and specialty physicians) to develop
protocols/guidelines.
• Consider high cost or high complexity conditions. • Simple and concise
• What needs to be done? Medical necessity-first priority. • What doesn’t need to be done?
• Where are clear trigger points for “referral” or “transfer?” • Treating the patient vs. treating “litigation” potential.
Collaboration with ER
staff and clinic staff.
•ER nurse participating on Health Care
Home (Medical Home) care teams.
•Patient specific (5%/50%)
•Condition specific(? %)
On-site or on-call social
worker/mental health
provider.
Ex: Patient given PHQ 2 or PHQ 9 in ER for depression screening
Warm Handoff to SS Make Appt. with PCC SS Follow up
Patient scores positive (high
potential for depression) from
Social issues drive
overutilization and
non-adherence as much or more
than medical issues.
Emergency departments play and will continue to play a very major and a very important role in
healthcare.
They are not exempt from the obligations
addressed in the Triple Aim; moreover, they are critical to achieving these goals and helping clinics
demonstrate quality care as in the Minnesota Community Measurement.