Potentially Preventable Emergency Department Visit Recommendations

Date: July 11, 2024
 
Attention: Primary Care Providers (PCPs)

Call to action: Texas Children’s Health Plan (TCHP) has seen an increase in emergency room visits, many of which could have been addressed in the primary care provider (PCP) office or an urgent care setting. TCHP tracks member potentially preventable ED visits (PPV) because they are a quality of care measure. PPVs are also costly and consume resources that other individuals with more acute needs may need. tcpi-changepkgmod-edvisits.pdf (cms.gov). In 2022, there were approximately 1.58 million potentially preventable emergency room (or department) visits (PPVs) in Texas Medicaid and Children’s Health Insurance Program (CHIP) programs, resulting in Medicaid and CHIP expenditures of approximately $754 million. Initiatives to Reduce Avoidable Emergency Room Utilization and Improve Health Outcomes in Medicaid March 2024 (texas.gov)

TCHP shares a commitment with our network providers to ensure that our members receive exceptional quality of care.

To support your efforts to deliver quality care and prevent unnecessary ED visits, TCHP would like to offer the following best practice recommendations.

Best Practice Recommendations for Reducing Potentially Preventable Emergency Department Visits (PPV):

• Increase appointment availability and provide flexible options for acute care:
  • Adapt your schedule template to include access to more same-day sick visits and include virtual care as an option.
  • Offer extended practice hours to include evening and weekend appointments.
    
• Address non-medical social determinants of health and other barriers to attending visits (e.g., transportation issues):
  • TCHP Case Management is here to help with coordination of care and connecting members to resources like transportation or other social needs. Case Management can also assist with tailored coordination of care for members’ chronic health conditions like asthma, behavioral health conditions, and diabetes.
    • The Case Management referral form is available here: https://www.texaschildrenshealthplan.org/providers/resources/forms-and-manuals
    • Providers can also contact the Case Management Team at the following phone number: 832-828-1430.
  • The Provider Alert on social determinants of health can be found here: https://www.thecheckup.org/2023/06/06/provider-alert-screening-and-coding-for-social-determinants-of-health-introducing-texas-childrens-family-resources/.
    
• Train practice staff on how to educate patients about the Role of the Primary Care Provider:
  • Train your practice staff on how to educate patients on the following topics:
    • When patients should seek urgent care
    • How patients can recognize emergency situations
  • Develop several test scenarios around the conditions that TCHP has noted as the most common reasons for preventable emergency department visits (PPV). According to January 2024 data from the Texas Healthcare Learning Collaborative, the most common preventable ED visits for the TCHP STAR Kids, STAR, and CHIP lines of business were attributed to the following conditions:
    • Fever
    • Infections of the upper respiratory tract and otitis media
    • Viral illness
    • Non-bacterial gastroenteritis, nausea and vomiting
  • Test and evaluate patient-facing staff members on these example PPV scenarios to ensure that the staff training was effective.
• Encourage chronic disease management to prevent or reduce exacerbations in chronic health conditions (e.g., asthma, diabetes mellitus, and sickle cell diseases). You can find additional information here: Member_Referral_For_Case_Management_8_2023.pdf (texaschildrenshealthplan.org)
• Educate patients and their caregivers on the following topics:
  • The crucial role of the Primary Care Provider (PCP).
  • Making appropriate decisions about where to seek care.
    • Skip the Wait: TCHP members have a variety of options to help them receive the care needed in the right place at the right time. Additional information on how members can receive medical treatment quickly for a non-emergency can be found here: Skip the Wait | Texas Children's Health Plan (texaschildrenshealthplan.org)
      • One example of a Skip the Wait resource is Texas Children’s Anywhere Care. Additional information regarding Anywhere Care and after-hours care are below.  
  • When to recognize a true medical or behavioral health emergency that requires immediate emergency medical attention at an emergency department.
    • Refer patients to Texas Children’s website to bookmark this helpful website on their mobile device. This information lists examples to help patients decide between urgent versus emergency care options. The second link offers alternative options for after-hours care: https://www.texaschildrens.org/urgent-care/about/urgent-care-vs-emergency-care and ER Alternatives available here.
  • The importance of maintaining an ongoing relationship with their PCP to promote consistent and coordinate health care.
  • The importance of having at least one wellness exam or preventive care visit each year, or more frequently based upon recommendations of the periodicity schedule.
    • Provider Alert on the infant well-child information can be found here:
      https://www.thecheckup.org/2024/02/29/provider-alert-infant-well-child-visit-reminder/.
  • After-hours care information:
    • Texas Children’s 24-Hour Nurse Advice Line – Gives the opportunity for patients to talk directly to a nurse. The free phone number is: 800-686-3831. Nurses are available 24 hours per day, 7 days per week to help patients with receiving care guidance and advice when needed.
    • Texas Children’s Anywhere Care – Whether day or night, TCHP members can have an online visit with a health care provider to treat a variety of routine medical conditions. Additional information on Anywhere Care can be found here: Anywhere Care | Texas Children's Health Plan (texaschildrenshealthplan.org)
    • Virtual Care Options – Additional virtual care options are available to TCHP members. Find out more information here: Skip the Wait | Texas Children's Health Plan (texaschildrenshealthplan.org)
      

Next steps for Primary Care Providers: PCPs are strongly encouraged to incorporate the recommendations listed above into their practice operations. Additionally, providers should share the alternatives for after-hours care with their patients to facilitate timely care delivery. 

If you would like additional clinical education or support, please email the Clinical Practice Consultant at: clinicalperformance@texaschildrens.org

If you have other questions, please email Provider Relations at: providerrelations@texaschildrens.org.

Some network Primary Care Providers (PCPs) may qualify for our Provider Incentive Program regarding this topic. Please reach out to your Provider Relations Liaison or Account Lead for more information. If you are unsure of their contact information, visit this page https://www.texaschildrenshealthplan.org/for-providers/meet-our-team or email Provider Relations at: providerrelations@texaschildrens.org. For access to all Provider Alerts,log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.