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How the University of Colorado Health cut the total cost of ED patient care by 18%, in 6 steps

November 15, 2018

    Reducing avoidable ED utilization is a top priority for every population health. However, ED optimization is often a missed opportunity to right-size utilization. Inefficient EDs threaten the ability to accommodate growth of covered lives and risk financial loss under value-based care arrangements due to:

    • High volume: EDs at or above capacity result in overcrowding, resulting in unnecessarily long visits, medical errors, and mortality;

    • High complexity: Even though the average ED patient is more clinically and socially complex, many EDs are not set up to address these needs—leading to frequent and avoidable acute utilization; and

    • Low compensation: While the costs of ED visits are increasing, payment policies have started to withhold reimbursement for some utilization, decreasing compensation. For example, some private payers don't reimburse for non-emergent ED use.

    Due to these pressures and significant inefficiencies, University of Colorado Hospital (UCH) redesigned ED services. The hospital's transformation leaders reduced avoidable admissions by 20% and total cost of care per patient by 18% within one year. Here are six lessons we learned from UCH's redesign process:

    1. Empower frontline staff to address operational inefficiencies: To prepare for large-scale change, frontline staff participate in weekly multidisciplinary forums, with executive support. UCH involves frontline staff in decision-making on changes related to clinical quality and safety, process improvement, and clinical operations.

    2. Instill a culture of process improvement: UCH developed Rapid Process Optimization (RPO), a clinician-led process improvement methodology, to formalize continuous improvement biennially. It provides a forum to inform and revise changes, making clinicians more likely to embrace change. UCH also ensures data transparency across all staff through role-specific performance dashboards. The dashboards compare individual performance to department and national standards.

    3. Ensure top-of-scope care delivery: A staff allocation analysis revealed that doctors and nurses spent more than half of their time on tasks beneath their skill level (e.g., turning over beds, searching for equipment). In response, UCH redeployed clinical and non-clinical staff to ensure "top-of-scope" care delivery. Investments in support staff and training ensure all team members operate at the top-of-role and encounter few ancillary delays.

    4. Embed standardized clinical pathways in EMR: UHC's standardized clinical pathways drive efficiency and ensure high-quality care. To kick off the pathway, an ED pivot technician (tech) collects basic information when a patient arrives. Then, the pivot tech directs critical patients to the main ED and non-critical patients to one of four intake rooms. UHC's non-admitted patient length of stay is now just 2.3 hours, and average door-to-doc time is 8 minutes.

    5. Designate ED staff for follow-up and transitions care: UCH expanded transition services to meet complex patients' long-term needs and prevent avoidable utilization. The hospital created a dedicated ED-based care management team (i.e., navigators, nurse care managers, social workers) to improve care transitions between the ED and ongoing clinical and non-clinical support (e.g., social services, PCP, skilled nursing facility).

    6. Establish partnership for sustainable, ongoing care: The transitions team connects high-utilizer patients to its Bridges to Care (B2C) program through a partnership with local FQHCs. UCH leadership ensure care transitions staff cultivate relationships with the B2C team. This arrangement has been key to B2C referral uptake, as warm hand-offs are now personalized (e.g., "Jane is B2C's care coordinator and will help enroll you in Medicare"). After this warm hand-off, patients receive wraparound support, including personalized care planning, health coaching, and behavioral health support.

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