Again, the answer to this question is impeded by the fact that it is front-loaded with the ill-defined term “non-emergent” coupled to a request for a percentage answer that would itself be contingent on some agreed upon definition of that term.

6. Do you keep statistics related to:

• Diagnosis
• Time of day, day of week
• Any other factors for ED visits
• Review of the findings

PaACEP does not serve as a warehouse for such statistical information. All hospitals and individual ED practices collect such data elements, and there would be significant variability expected among institutions within the Capital BC CHIP catchment area.
In a published report, “Potentially unnecessary emergency room visits in upstate New York”, Excellus BC/BS defined potentially “unnecessary” visits as those that either “didn’t need care within 12 hours, or that did need care within 12 hours, but could have been treated in a primary care setting.” Of these cases, only 45 percent were seen during typical working hours of 9 a.m. to 5 p.m. while 46 percent were seen between 5 p.m. and 6 a.m. The highest percentages of potentially unnecessary visits were seen on Sunday (44.6 percent of cases that day) and Monday (44.5 percent). The large diagnostic categories (not limited to a CHIP population) were visits for back disorders, acute upper respiratory infections, ear infections and sore throats.

7. What barriers do you think are of significant importance to target to reduce unnecessary ED visits?

Refer to question 4.

In summary, the issue of the adequacy of resources within the primary care network remains the principal determinant, assuming there is agreement as to the definition of “unnecessary.”

8. What types of actions/interventions can be developed to reduce unnecessary ED visits?

In sustaining and perhaps augmenting the primary care network essential to the optimum functioning of the Capital BC CHIP program, perhaps no development offers more direct benefit than the Primary Care Incentive Program (PCIP) included in the provisions of the Patient Protection and Affordable Care Act (PPACA). By reimbursing primary care providers to Medicaid beneficiaries at Medicare rates, PCIP should provide strong financial incentives to see patients, expand their operational hours, and develop programs to improve access.

PaACEP is unaware of current operational standards of the Capital BC CHIP Program or what new initiatives might be in the process of development. That being said, by way of potentially useful interventions, we would cite the following:

• Expansion of the Capital BC CHIP primary care network: To what extent insufficiencies in the number of primary care providers contributes currently to potentially unnecessary ED visits is uncertain. However, the predictable expansion of CHIP enrollees through provisions of PPACA would seem to mandate a concomitant increase in the number of available providers.
• Increased hours of operation by primary care providers: Many parents of CHIP beneficiaries have regular full time jobs that make it difficult for them to bring their children in or benefit from phone consultations during working hours. In the Excellus NY database, expanding availability of primary care providers until 9 p.m. would have accounted for two thirds (67 percent) of those hours when patients sought ED care. Additionally, more robust weekend coverage would catch at least some ED visits; in the Excellus report, 43.3 percent of ED visits on Saturday were potentially unnecessary and 44.6 percent of those on Sunday.
• Enhanced availability for phone consultations: A significant number of ED visits might be resolved by thoughtful professional reassurance of the parents. After hour ED visits in the Excellus report showed 22 percent occurring between 5 p.m. and 8:59 p.m., 13 percent between 9 p.m. and 11:59 p.m., 11 percent between 12:00 a.m., and 9 percent between 6 a.m. and 8:59 a.m.
• Open access scheduling: This tactic involves setting aside designated provider hours for unscheduled office visits.
• Coordination of ED and Primary Care Services: Continuity of care for CHIP subscribers requires adequate communication between the ED and PCP. Notification of the PCP by the ED provider doubtless occurs in all serious cases. For more minor ED presentations, the presence of an enterprise-wide electronic health record would be expected to provide a shared patient information database, including recent ED encounters. Absent such a shared EHR, it is incumbent on Emergency Physicians to make the PCP aware of the CHIP patient visit either through transmitted copies of the discharge instructions or the medical record itself.
• More appropriate utilization of specialized services for frequent ED users: Some portion of “unnecessary” ED visits may relate to children and adolescents with mental health or substance abuse issues. The limited availability of follow up care in these categories may result in over utilization of the ED and improved coordination and increased availability of these services represent a potential opportunity for improvement.
• Increased availability of “retail clinics”; Walgreens, Walmart and other corporate enterprises have instituted walk-in services staffed by mid-level providers (Nurse Practitioners) to address a limited spectrum of clinical presentations. Capital BC should monitor this development with respect to both cost and quality of care parameters.
• Potential contribution of Telemedicine: This modality is coming into use in some ED’s and has potential to expand to other provider venues. Capital BC should encourage promulgation of this addition to the potential spectrum of patient care, and assure that existing contracts with its providers allow for appropriate reimbursement
• Improved coordination of care for children with chronic diseases: A number of ED visits result from children with chronic conditions whose management requires ED care only in the context of unusual or unexpected circumstances. Improved coordination of outpatient care options for these patients would eliminate potentially unnecessary ED visits.

9. Do you think it would be valuable to collaborate on this initiative with Capital Blue Cross and Primary Care Practitioners to further investigate/test interventions to reduce unnecessary ED visits?