Kaiser Permanente has used narcotics contracts effectively to reduce avoidable ED use by "high utilizers" and redirect patients to more cost-effective care venues, explains Sara Tracy, M.S.P.H., senior manager of emergency services at Kaiser Foundation Health Plan of Colorado.
We classified our high utilizers - our resource intensive members that are also referred to as "frequent fliers." We identified these people as low, medium or high users. Our low members are those that had two ED visits in three months; medium were those that had either three, four or five visits in six months; and our ultra-high utilizers were those that had six or more visits in a year. We did a data pull based on claims data that helped to identify those that had a connection with either chemical dependency, behavioral health or no connection at all. Our data pull included information on the primary care physician (PCP), the EDs they've visited including the dates and the diagnosis, the top prescriptions that were prescribed for the member and the dollars that were spent on these members.
We identified approximately 1,000 members that fall within these guidelines. The first group we looked at were those individuals that have a known association with chemical dependency. Those are members who have had a referral or a visit with someone in our chemical dependency department within the last year. Many if not most of these members were patients who had issues with narcotics. We pulled a chart review of 25 members to identify those that had a current narcotics contract, which is an agreement between the physician that's prescribing the narcotics and the patient on the parameters for the prescription. Often, these members would request early refills; they may show up to the ED in pain requesting IV narcotics. The narcotics contract is very critical to helping keep these members compliant. We found in our review that only 20 percent of that population had a contract. When these members subsequently show up in the ED and there's no contract available, the ED does not have much guidance in terms of, "How do we treat this member?"
We reviewed our current narcotic contract format and decided that it was very lengthy, rather robust and not user friendly. We have worked with our chemical dependency department to revise that contract to be a one-page contract. It is very succinct; it includes 10 bullet points that the member initials and has all the parameters under which the physician will prescribe narcotics for that patient.
Additionally, with these subsets of patients, we outreached to very specific PCPs to try to engage them in establishing a contract. If a member was receiving narcotics and had multiple ED visits and did not have a contract, we outreach to the PCP to get one in place. We additionally identified a standardized place in the chart where the contract was located so that it was easily found by anybody accessing the chart.
Finally, we provided a high level summary of the sig (instructions) for the contract, which included the patient receiving a certain number of oxycodone, which they would get once a week. Only this provider can refill it and there are no early refills. Additionally, most providers would put information in the contract about what to do if the patient showed up in the ED, which included "May not receive any additional narcotics" or "Must notify ED is on a narcotic contract."
Our final strategy in addressing this population was outreaching to our core ED to ensure that the contract information was copied into a medical record at that hospital. This ensured that when that patient showed up, no matter who saw them, they were able to see the contract.
Source: 27 Interventions to Reduce Avoidable ER Use, November 2010
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27 Interventions to Reduce Avoidable ER Use
This resource describes 27 separate initiatives launched by Kaiser Foundation Health Plan and WellPoint around the country that are effectively reducing avoidable emergency department use and redirecting patients to more cost-effective care venues.
27 Interventions to Reduce Avoidable ER Use is available from the Healthcare Intelligence Network for $167 by visiting our Online Bookstore or by calling toll-free (888) 446-3530.