As the U.S. opioid abuse epidemic rages on, the emergency department is acutely feeling the impact of this trend. According to a 2014 study, the number of ED visits in which narcotics were prescribed has increased by 10% over the last decade.
OSF Saint Luke Medical Center, a 25-bed critical access hospital in Illinois, has taken steps to solve this problem in their community. In 2013, the organization implemented a therapeutic contract program that successfully reduced ED utilization by 308 visits from 2013-2014, resulting in approximately $443,000 in savings from cost avoidance. The key success factor was activating patients—and PCPs—to more effectively manage care. Here’s how they did it.
How OSF's therapeutic contract program works
OSF Saint Luke saw high ED utilization as a big patient quality and cost savings opportunity. 40% of its top users visited the ED over ten times in 2012. Most often, those users received a pain-related diagnosis such as migraines, chronic pain, painful breathing or lumbago.
Hospital staff recognized that this group likely included patients addicted to narcotics, who had not worked with a provider to build an effective plan to tackle their pain and addiction issues. As a result, they were unnecessarily utilizing care and putting a financial and capacity strain on the ED. Narcotic-seeking superutilizers were filling beds that should have been filled by patients appropriately seeking care in the ED, who were also more likely to be profitable cases.
To tackle this issue, OSF Saint Luke launched a therapeutic contract program in 2013 with 26 of their highest ED utilizers. Through this program, the ED medical director sends a letter alerting both the patient and the patient’s PCP that the patient will no longer receive narcotics in the ED for a chronic pain diagnosis until receiving a contract from the PCP with instructions as to how the issue should be managed. From there, the PCP is responsible for working with the patient to develop a care plan which stipulates how many times, from one to three, the patient can visit the ED per month for evaluation and treatment of his or her chronic pain condition.
The PCP notes this figure on the pain contract. The PCP and the patient sign the contract, and the PCP returns it to ED staff. The contract is referenced each time the patient visits the ED, and ED physicians are held accountable to the terms outlined for appropriate narcotic use. During this process, PCPs can also connect patients with resources to better manage their health issues, whether they stem from true chronic pain or narcotic addiction.
OSF's letter to patient and his or her PCP
OSF's pain contract
Why OSF's program was successful
Leaders at OSF Saint Luke attribute their program’s success to three key elements:
1. Strong ED physician buy-in
From the start, OSF Saint Luke involved its Medical Director of ED in the roll-out of therapeutic contracts by tying reduction of ED use to the position’s incentive pay. As a result, the Medical Director has invested in training physicians on the program. The greater medical staff is also supportive of the program, as it provides them with clear parameters for patient treatment. Now, when staff recognize a patient who may be a high-utilizer, they drop a label with the patient’s name in a designated box so the ED utilization team knows to review the patient at their next meeting.
2. Regular meetings to identify participants and monitor utilization
To identify high-utilizers and ensure patient compliance with the therapeutic contract, OSF Saint Luke created an ED utilization team, including the Director of ED, Medical Director of the ED, Director of Quality, Utilization Review/Patient Advocate RN, and rural health Clinic Director. This team meets on a bi-weekly basis to identify which patients should participate in the program, determine who will take the lead on contacting the patient and their PCP, and evaluate any patients who have broken their contract. The team also discusses behavioral and social trends among high utilizers of the ED to determine how to best manage their care.
3. Provider accountability when contract is violated
The medical director of the ED follows up with any physicians who violate the therapeutic contract to understand why the error occurred. However, ED physicians are largely on board with the contracts, and there has only been one contract violation since the program began in 2013.
OSF Saint Luke’s therapeutic contract program enables community PCPs and the ED to form a united front to better manage care. Previously, if a PCP refused to prescribe narcotics, a patient could simply obtain the medication from the ED. This is no longer the case. Now, the ED triggers PCPs to have conversations with patients about alternative treatment plans. The pain contract has been the catalyst for PCP and ED partnership to provide the right care for each patient.
During the program’s first year, OSF Saint Luke successfully reduced ED utilization by 308 visits, resulting in approximately $443,000 in savings from cost avoidance. 15 out of the 26 patients reduced their utilization of the ED by more than 50%. In 2014, OSF Saint Luke was awarded the Innovation of the Year award from the Illinois Critical Access Hospital Network for its approach to reducing ED utilization.
Due to the program’s overwhelming success, OSF Saint Luke increased the size of its ED utilization program to 100 participants in 2014 and later merged it with the existing readmission reduction program.