Testimony of

Sue Blankschaen, RN, Administrative Director, Ambulatory Services
University Hospitals Case Medical Center
Cleveland, Ohio
September 16, 2015
Before the Ohio House Healthcare Efficiencies Summer Study Committee

Chairman Huffman and Members of the Healthcare Efficiencies Summer Study Committee, my name is Sue Blankschaen. I am a registered nurse and the Administrative Director for Ambulatory Services at University Hospitals Case Medical Center. I am grateful to have the opportunity to provide testimony on the University Hospitals Medical Access Clinic, an emergency room avoidance program that has been successful in promoting better health, decreasing cost, and improving patient care. I commend the Committee for its work in investigating ways in which our healthcare system can be more efficient, and I look forward to offering any assistance I can.

Case Medical Center is University Hospitals’ 1,032-bed, tertiary medical center. UH Case Medical Center is also comprised of University Hospitals Rainbow Babies & Children’s Hospital, University Hospitals Seidman Cancer Center, and University Hospitals MacDonald Women’s Hospital. As a System, UH and its partner hospitals is Northeast Ohio’s second largest private sector employer.

When a non-UH hospital closed in 2011, the Center for Emergency Medicine (CEM) at UH Case Medical Center saw a 20 percent increase in visits, with many of them for lower acuity issues. An analysis showed that the majority of these patients were either uninsured or covered by Medicaid. We realized that many of these patients would be better served if they accessed care in a more appropriate primary care setting. We also wanted to reserve emergency room beds for true emergencies. Therefore, collaboration between the CEM, UH Family Medicine and Ambulatory Services led to the concept of the Medical Access Clinic (MAC).

The MAC opened in November 2013 in clinic space near the CEM. Protocols were developed to determine the types of patients that would be appropriate for the MAC. Those determined to need non-emergent care are diverted from the emergency room to the clinic.

The goal of the MAC is to treat the problem for which they sought care, but more importantly, to reduce unnecessary visits to the emergency department by developing a point of entry into primary care. The process begins in the CEM where patients are triaged by a nurse practitioner. When the patient is seen in the MAC, care is provided by a team of providers that can include a nurse practitioner or physician, nurses, medical assistants, and a social worker.

The MAC is much more than a place to receive care. It is also an educational resource. Once a patient is treated in the MAC, they are provided education about the importance of establishing a relationship with a primary care provider and how to seek care in an appropriate setting. They are also taught how to manage their health and medical conditions, and explore why they do not use traditional health care for their issues. Barriers to using existing primary care resources are explored and addressed by a social worker and nurse. When appropriate, patients are given assistance in applying for insurance or enrolling in Medicaid. Those that are insured are taught how to properly utilize their benefits. They are given a follow-up appointment with a primary care clinic or in the MAC. The key is that a nurse or social worker follows up with the patient to provide continued assistance, ensure instructions are being followed and provide any ongoing education or support. Patients were encouraged to call and check in, ask questions or express concerns.

Since opening we have seen about 5,300 patients in the MAC. That is 5,300 unnecessary emergency departments avoided. Most of our patients are young – between the ages of 18 and 39 – and the vast majority do not have a primary care provider (PCP). Of those with a PCP, many are unable to get a timely or convenient appointment for their current illness. This type of analysis has been helpful in guiding the program to meet patient needs and to influence patients’ health care decisions.

The MAC has overwhelmingly exceeded all expectations – only one percent of the patients who have utilized it have returned to the CEM for non-emergency care. The number of patients seen continues to grow as the referral process improves. The MAC has favorably impacted the CEM by increasing capacity for more acutely ill patients, promoting throughput, and reducing the number of patients who were leaving without being seen.

Operating the MAC has taught us a great deal about the barriers to pursuing and accessing primary care services, including:

  • Lack of transportation to appointments;
  • Lack of child care;
  • Patients’ inability to plan ahead when scheduling appointments;
  • Patients’ difficulty in navigating scheduling systems;
  • Difficulty in getting appointments in a timely manner for the issue at hand;
  • Perception that the urgency is greater than it actually is;
  • Lack of adult advice line services;
  • Difficulty following or understanding instructions;
  • Confusion or misperceptions about how insurance works; and,
  • Lack of “family” or “couple” appointments for common issues.

The next phase of the MAC is to open a primary care setting with flexible scheduling and full nursing and social service support between visits. The MAC has succeeded in reducing costs by providing care in a more appropriate setting, and by promoting health and wellness care.

Thank you for this opportunity. I am happy to address questions you may have.