CPT Melissa ThomasFinal Project Portfolio
Best Practice and
American Hospital Association NOVA Award
Submission
Department of Primary Care Nurse Greeting Center
in the Emergency Department
Point of Contact: LTC Richard Behr, Clinical Nurse OIC, Department of Primary Care,
, 719-524-5664
Group involved with the project:Evans Army Community HospitalDepartment of Primary Care (DOPC) (to include all outlying clinics); Emergency Department (ED); Resource Management Division; Medical Management Division; Medical Treatment Facility (MTF) leadership
Submitted by CPT Melissa Thomas
May 10, 2012
Executive Summary: A nurse greeting center staffed by the Department of Primary Care was established to reduce non-urgent care in the Emergency Department. The greeting center obtains patients a same day appointment or refers them to their assigned clinic on a walk-in basis. In eight months, 2,040 patients were redirected saving $137,000.
Objective of the Best Practice: A nurse greeting center staffed by the DOPC in the ED in Evans Army Community Hospital (EACH) was established to reduce non-urgent patient care in the ED, thus advancing patient safety, improving continuity of care, and reducing waiting times and costs.
Background: Military MTFs are in the process of implementing patient centered medical homes (PCMH) to improve provider continuity with their primary care manager, patient satisfaction, and overall health outcomes. Additionally, the Performance Based Adjustment Model (PBAM) both financially incentivizes and punishes certain patient behaviors and health system management processes. One such decrement is a penalty for non-emergent RVUs seen in the ED, and one such reward is for provider continuity. Due to these factors, a multidisciplinary team was formed to address the goal of reducing non-urgent care in the ED without hiring additional staff. An observation period determined a potential for improvement in the triage system and acquiring appointments for patients who presented at the ED with non-urgent issues.
Literature Review: Inappropriate emergency department utilizationis common worldwide; therefore a lot can be learned about the Department of Defense population from studies of populations in countries with socialized medicine. Studies in Brazil and Singapore show that inappropriate use of the ED was due to unavailability of primary care appointments or an overestimated self-perceived urgency. Success in changing patient behavior was achieved through education/campaigns about the appropriate use of medical services as well as financial incentives, which must be combined with expanding access to primary care for the best effect (Anantharaman, 2008 and Carret, Fassa, & Kawachi, 2007).
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CPT Melissa ThomasFinal Project Portfolio
Implementation Methods: The method used at EACH was establishing a nurse greeting center staffed by the DOPC co-located with the ED triage registered nurse (RN). The nurse greeting center is manned during daytime hours consisting of a Primary Care RN and medical staff assistant familiar with the appointment booking system. The RN triages patients for clinic appointments when the visit is clearly non-urgent as well as educates patients on non-urgent conditions and procedures for obtaining appointments. If no appointment is available, patients are referred to their assigned clinic on a walk-in basis following direct telephonic communication with the accepting clinic.
Results: Implementing this process resulted in a statistically significant rise in the percentage of patients triaged out from the ED to a primary care clinic (shown in Figure 1), as well as a statistically significant drop in the percentage non-urgent of total ED patients (Figure 2). In eight months, over 2,040 patients were redirected to a primary care clinic with a cost savings of $137,000 (using $67.10 per patient cost difference of a primary care encounter versus ED visit).
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CPT Melissa ThomasFinal Project Portfolio
Conclusion: This program is easily replicated in its entirety at every DoD Facility with an ED without additional funding. One unique element is utilization of primary care nurses and staff to implement the program who are familiar with the scheduling process and various available clinics, versus Emergency Department staff, which was tried at other military facilities, which adds to their workload and is out of their scope of responsibility. Additionally, this program is unique in that it did not require any additional funding or staff, although now that the pilot program is complete, the process is in place to hire an RN solely for this position to minimize the impact of periodically losing an RN from the primary care clinics for a day.
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CPT Melissa ThomasFinal Project Portfolio
Figure 1. Percentage of ED Patients Triaged Out from the ED to a Primary Care Clinic. This figure compares the average percentage of patients triaged out before and after project implementation.
Figure 2. Percentage of Non-Urgent Patients of Total ED Patients. This figure compares the average percentage of non-urgent patients seen in the ED before and after project implementation.
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CPT Melissa ThomasFinal Project Portfolio
References
Anantharaman, V. (2008). Impact of health care system interventions on emergency department
utilization and overcrowding in Singapore. International Journal of Emergency Medicine, 1:11-20.
Carret, M., Fassa, A., & Kawachi, I. (2007). Demand for emergency health service: factors
associated with inappropriate use. BioMed Central Health Services Research, 7(131).
Meyers, M. (2003). Changing business practices for appointing in military outpatient medical
clinics: the case for a true “open access” appointment scheme for primary care. Journal of Healthcare Management, 48(2): 125-139.
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