Why the Program Matters
American’s reliance on the hospital Emergency Department continues to soar, even though many of these visits could have been prevented with timely access to primary care. When someone has a regular medical home, they have a better chance at good health, which in turns generates cost savings to hospitals and payers.
With mounting concerns over rising health care costs and rising rates of emergency department visits, payors across every state have been looking at strategies to control Emergency Department spending over the last several years—that is where the Foundation for Complex Healthcare comes in with the Enhanced Care Program.
How the Program Works
When high-utilizing patients (that were part of the Indiana High Risk Pool or the ISDH HIV health plan) enter the emergency department, staff in the hospital are trained to immediately engage in assessment, discuss the intervention process, and enroll members in the Enhanced Care program.
The Foundation for Complex Healthcare Solutions works with several emergency department avoidance programs such as IU Health, Regenstrief Institute, ISDH, and Park Center. Hundreds of participants are identified as high utilizers and are enrolled in a program from multiple hospital settings. Bi-weekly calls are established with the healthcare program administrator and/or broker to review claims data and identify members that are frequent ER utilizers. A specialized case manager reaches out to each of the members and their other healthcare providers to determine medical necessity. A plan is developed with each of the members on alternative methods of care and determination on when the emergency department was the best choice of care delivery. In many cases, the patient needs primary care resources as opposed to emergency department resources. With today’s increase in telehealth options, there are even more ways for patients to access care without using the emergency department as the first option.
Program Results Overview
Results of the Enhanced Care program include breaks in previous emergency department utilization trends, lower patient claim costs, and higher patient adherence and quality of life.