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Emergency Patient Interdisciplinary Care (EPIC) - The Way Forward

Monday, July 1, 2013

Emergency department's pilot project hopes to help nation's health systems adapt to life under the Affordable Care Act.

By: Alice Patenaude

The Affordable Care Act is changing the landscape of healthcare for both patients and health systems across the country. The ACA, passed in March 2010, has already allowed patients to take greater charge of their health by requiring insurance companies to fully cover preventive care and by prohibiting the denial of insurance coverage because of pre-existing medical conditions.

Healthcare organizations, like the University of Illinois Hospital & Health Sciences System, will face both opportunities and challenges as the ACA continues to shape the future of healthcare. They will see an influx of newly insured patients but also lost revenue as reductions in Medicare and Medicaid reimbursements take effect under the provisions of the ACA.

In the next phase of the ACA's rollout in January 2014, more than 48 million uninsured Americans will have expanded access to health coverage through two primary methods-an insurance exchange, where individuals and small businesses can buy qualified health benefit plans-and an expansion of Medicaid, depending on the state where patients reside.

The new insurance marketplace will allow consumers and small businesses to examine their insurance options and to purchase healthcare plans, with open enrollment beginning in late 2013. In Illinois, Medicaid expansion, which will expand coverage for 342,000 newly eligible residents, passed the Illinois Senate in late February, but as of this publication date-has not yet passed the House. The House was to begin debate on the expansion in late May.


An initial step UI Health is taking this summer is the UNISON Health survey (see page 17); a community health needs assessment of 1,400 community members. "A lot of people may not understand the 'language of insurance' if they haven't been in the healthcare system in awhile, so we will also be providing information about how people can learn more about the ACA and how to enroll in insurance," says, Nicole Kazee, PhD, director of health policy and programs for UI Health.

"In our primary service area-the ZIP codes around the hospital that have the largest proportion of our patients-just over 25 percent are uninsured right now," says Kazee "Insurance expansion is good for the community and good for us since there will be less uncompensated and catastrophic care. We need to be ready to accept a lot of new patients."

UI Health's Mile Square Health Centers will be a big part of providing care for those new patients. A network of community health centers, Mile Square is the first line of defense for area patients, providing primary care for patients right in the neighborhoods in which they live. A new clinic at the southwest intersection of Wood Street and Roosevelt Road, built in part with a $12 million ACA-funded grant, is slated to open later this year.

"The clinic is an important part of our strategy for managing care for new patients," says Kazee. "But we also want to make sure that patients understand their eligibility for the new insurance options and how to enroll. We will partner with the state of Illinois as they start to develop their strategies."


The ACA also includes funding for demonstration projects to test new ways for hospitals to be paid by Medicare and Medicaid. For example, rather than receiving a payment for each individual service patients receive, these projects will bundle payments so hospitals, doctors and other providers will be paid a flat rate for each episode of care such as a heart attack. Going forward, there will be an increased emphasis on coordinating care throughout the health system as all payers begin to shift to the models of bundled or global payment.

Responding to the cuts in Medicaid and Medicare reimbursement and the changing reimbursement models, UI Health is looking at ways to streamline the cost structure and make it more efficient, while focusing on care delivery changes that will better manage the health of patients. One of the health system's most innovative initiatives is a recently launched pilot project in UI Health's emergency department, a site that sees 44,000 patients annually.

Recently named the winner of an internal competition for innovative ideas in care coordination, the Emergency Patient Interdisciplinary Care (EPIC) project brings a unique focus to improving patient care, while reducing costs for inpatient and emergency room utilization.

"The aim of EPIC is to bring interdisciplinary care coordination to the often-complex patients who are 'frequent visitors' to the emergency room," says Terry Vanden Hoek, MD, chair of emergency medicine and EPIC project leader. "Our goal is to leverage the great strengths across the health system to create a personalized care plan for patients, one that transitions them back to primary care, if possible, within 30, 60 or 90 days."

The "frequent ER visitors" addressed through the EPIC program are among the nation's 10 percent of patients who account for 70 percent of total health expenditures. Screening criteria for the program will include patients known to be at risk for poor outcomes-those who have had two or more hospital admissions, have two or more chronic diseases, take five or more medications or have had at least four visits to an ER within the previous year. Using information in a data warehouse, a "pop up" will alert staff of a potential complex patient who meets these criteria when presenting at the ER, prompting a consult from the EPIC team.

"These frequent visitors are patients with complex medical problems, fragmented care, lack of access to medical services and often have co-existent psychosocial issues," says Steve Brown, MSW, LSW, and associate director of clinical practice in the emergency department.


To address the needs of these complex patients, the EPIC project concept was developed by a team of clinicians and researchers from the colleges of Nursing, Medicine, Social Work and Pharmacy. When the program is officially launched in the summer of 2013, a core team of a nurse case manager, social worker, pharmacist, two community health workers and program manager will work together with patients who enroll in EPIC and their family members to develop a transition care plan.

Teaming Up Graphic

What sets EPIC apart is its interdisciplinary nature, bringing together the university resources that these complex patients need in addition to primary medical care-social workers who provide a conduit between the medical system and the family and who are trained to address psychosocial challenges; pharmacy to assist patients taking multiple medications; and other specialists-all supported by community health workers who can interact directly with patients and their families in their homes. "What happens after a visit to the emergency department becomes crucial," says Kathy Christiansen, RN, PhD, executive director of the Institute for Healthcare Innovation for the College of Nursing. "Our plan addresses what happens after the patient leaves the hospital so the patient is very clear about what to do next."

Innovative technology is another hallmark throughout the EPIC program. Hospital data will help to initially identify "frequent visitors" to the ER. Since patients often visit multiple ERs, further fragmenting their care and creating additional obstacles to sharing health information, a Health Information Exchange will alert non-UI Health physicians if one of their patients enrolled in EPIC seeks care at one of six Chicago-area hospitals. In addition, telehealth software and iPads will link community health workers to the EPIC team, creating "face-to-face" relationships with patients and pharmacists as they work together to remove barriers to proper medication use. Finally, a crowd-sourced website (www.PurpleBinder.com) will allow the EPIC team to find, track and share community resources.

"We anticipate that patient volumes will increase as the ACA continues to roll out," says Mark Mackey, MD, vice chair of operations and medical director for the EPIC program. "We have to do a better job of managing patients more cost-effectively and eliminating waste in the system. The interdisciplinary nature of the EPIC program, its innovative technology and the expertise of UI Health will allow us to produce a better coordinated care plan while reducing costs."

The EPIC team estimates that it will treat 547 patients annually, saving $5.4 million through reduced inpatient and emergency room utilization, while improving care and quality of life for patients.

"The stakes are much higher now if we send patients home and they get readmitted," says Vanden Hoek. "Under ACA we will be judged on how well we are taking care of our patients. We need to think about more effectively handling the transition of patient care, using community resources to take the best care of our patients. These issues are ones that every emergency department will face. The EPIC program is one that can be replicated in any ER throughout the nation."