Spectrum Health Targets ED Frequent Fliers for Primary Care

A new program at Spectrum Health in Grand Rapids, MI is identifying "frequent fliers" at the system's emergency departments and placing those patients with a multi-specialist intervention team.

The program, while only six weeks old, has steered more than 140 patients to the less-expensive coordinated care program and has saved the health system a net total of about $300,000.

"It's going really well—better than we had hoped," says R. Corey Waller, MD, a specialist in addiction and emergency medicine, and director of the Spectrum Health Medical Group Center for Integrative Medicine.

"We are focusing on getting the patients better and not decreasing ED visits, because if you do the one the other will follow," he says.

The program was launched in early December and identified about 950 patients who'd used the emergency rooms at Spectrum's Butterworth and Blodgett hospitals more than 10 times in a year. Those patients accounted for more than 20,000 total visits and up to $50 million in costs annually.

The center randomly contacted about 190 patients, 140 of whom agreed to the coordinated care treatment regimen.

"By the time we get them they are pretty broken and the ones that show up are the ones that want help. What we are seeing right now is going to be a skewed view to the person who is sicker and wants help because they are coming in willfully," Waller says.

"Once we get them into the center they stay because they realize the approach we take is different," he says. "We don't fire them and we tell them straight up we don't care what they are doing that may have irritated other doctors in the past. We just need to know it so we can come together with a plan."

The center's treatment team uses addiction specialists, psychologist, RN case managers, and social workers to confront not only the medical issues—often pain, addiction, or both—that are driving these patients into the ED, but also the psychological and social issues that may be exacerbating the problems.

"Most of these patients don't know what do to. They really want someone to guide them through this," Waller says. "There are times when the RN case manager or social worker is able to guide them better than I do. We work together with each of the patients after we do our intake. Any plan I come up with has to be in line with the psychological side and the social side. We manipulate our plans so they work together and we present that to the patient before we finalize the plan."

Waller says the patients are not chastised nor forced to agree to treatment plans dictated by the medical staff. "We don't have them sign any contracts and that is the big thing," he says. "If you have someone with true pain or who has a true neurobiological addiction who is not being treated they are not going to adhere to some contract because they don't see risk and benefit the same way we do."

The program is expected to grow as more eligible patients learn about it and understand that it's not a trick. 

"They're scared. They think it is a bust," Waller says. "When they realize we are trying to get them some help they come back. It's a matter of getting them to trust us. Now we have a core group of patients in the neighborhood saying 'they are here to help you out.'"

As many as 40% of the center's patients are neurobiologically addicted to some substance. Waller says the center has successfully developed a treatment regimen that couples medication with behavioral therapy and modification. "More than 90% have stayed clean since they started treatment here," he says. 

The net savings of $300,000 in six weeks and the drop in ED use has attracted the attention of payers, including commercial insurers with Medicaid plans.

"I just want them to pay for an episode of care. 'You give me the money we will get them better.' It is a small amount of money but it helps us to get closer to solvency," Waller says. "This is not a clinic built to make money but to save money. What we are trying to do is make sure that it is a sustainable business model. Right now we have a three-tiered payment system. We get $700 for an easy patient, $1,400 for a medium patient, and $2,100 for a difficult patient. And that covers everything. It saves a ton of money."

The center has kept detailed data on the program.

"The goal is to come up with a screening tool so we can identify them on visit No. 2 to the ED and get them the social or psychological or medical services they need before they turn into high frequency use," he says.

With the implementation of the Affordable Care Act, Waller says Spectrum's model could provide an affordable way to control healthcare costs for that high-usage population.

"One of the biggest issues is how do we create comprehensive care and still pay your bills? If you try to create comprehensive care in every doctor's office you will lose your shirt," he says.

"What needs to happen is a model like this that is more of a specialty place where you filter patients so that everyone who has a questionable issue or multiple issues would come through here and be medically, psychologically and socially evaluated and stabilized."

When that's done, Waller says, the patients can be transferred to a traditional primary care environment. "All they have to do is maintain it," he says, "because it becomes so expensive if every doctor's office has to have a psychologist or a social worker or five RN case managers."

Waller says he wants to show other health systems how to replicate Spectrum's success.

"We are retooling efficiencies right now," he says. "The reality is you have to have appropriate through-put without marginalizing the information we are getting. In two weeks we will have that on paper so we can have the billing codes and the ways it has to be documented set up."

"Within two to three weeks we are going to be able to tell somebody how to replicate this if they would like to."