This report provides data that supports analysis, tracking and trending of avoidable ER trends by the facility, member, PCP, and diagnoses with cost and utilization provided.  The color-coded arrows offer the user a quick reference for positive (green) or negative (red) trends.  

 

 

Target Audience for this Report 

Chief Medical Officer, Compliance & Regulatory Department, Finance Department and CFO, Leadership Team, Medical management/Care Management Department, Pharmacy & Therapeutics Committee, Physician Relations, Quality Management, and Utilization Management.

 

Business Processes Impacted by this Report

Avoidable ER Rate informs the health plan of a key opportunity to reduce costs and improve care continuity by reducing this number.  Evaluating patient access to PCPs and Urgent care appointments is important in impacting this rate.

 

Network development of urgent care, telemedicine, and PCPs with access to care when members are ill, are all strategies that can be driven and monitored by this report.

 

Care management will link this report to members, PCPs, and diagnoses to create focused member support resulting in reduced ER utilization.

 

Behavioral health and pain management diagnoses represent a large number of Avoidable ER visits in many populations.   Developing programs and care plans which support members in an alternative setting could be effective in reducing these visits.

 

Education of members, families and employers about when and where to access care can improve this rate.  This can be provided on the health insurance card and reinforced by both the health plan and the employers.  Post ER communication by care managers can be effective in coordinating follow up appointments and preventing follow up ER visits.

 

 

 

Detail and Definitions

 

Header

  • Total ER Visits
  • ER Visits/1000
  • NYU Avoidable ER Probabilities:
    • Non-Emergent
    • Emergent-PC Treatable
    • ED Care Needed-Avoidable
    • ED Care Needed-Not Avoidable

 

Facilities

  • Facility
  • ER Visits
  • Non-Emergent
  • Emergent-PC Treatable
  • ED Care Needed-Preventable
  • ED Care Needed-Not Preventable

 

Primary Care Physicians

  • PCP Name
  • ER Visits
  • Non-Emergent
  • Emergent-PC Treatable
  • ED Care Needed-Preventable
  • ED Care Needed-Not Preventable

 

Members

  • Member Number
  • Member Name
  • ER Visits
  • Non-Emergent
  • Emergent-PC Treatable
  • ED Care Needed-Preventable
  • ED Care Needed-Not Preventable

 

Member ER Visits

  • Date of Service
  • Claim #
  • Member Number
  • Member Name
  • POS
  • Dx Description