Moving Consumers "Out of the ER" to Reduce Costs and Increase Efficiency

Blue Cross of California

Out of the ER: The Tulare Project was designed by Blue Cross of California (BCC) in 2002 when it discovered that Tulare County Medicaid members utilized the emergency room (ER) at a staggering rate. More than 66 percent of members were visiting the ER each year, many for non-urgent care, equating to more than 36,000 visits in one year alone. By working with local staff, clinic administrators and medical directors of three large clinic providers, as well as educating members through instructional materials, the Tulare Project successfully moved patients away from ER overuse to their PCPs for non-urgent care.

Program Elements

• Postcards printed in both English and Spanish were sent to members to remind them of available non-emergency healthcare services and encourage them to contact their local BCC office if they have questions regarding a PCP or scheduling routine appointments.

• Two self-care reference books available in both English and Spanish and covering basic childcare such as diaper rash, fever, simple cuts, etc, were distributed to members to help parents decide whether their child or teen needs to visit their PCP or go to the ER.

• In some instances, BCC and clinics worked together to develop adequate customer service and appointment scheduling, ensuring members received timely appointments at the appropriate venue.  They have also collaborated to develop a triage process for licensed professionals including communication training for clinic staff focusing on correct illness identification.

• Additionally, ER data from the hospitals will be shared with all Tulare County PCPs and clinics to show how many of their managed care patients have used the ER for routine issues.  The clinics can then contact patients for a post ER follow-up visit, and educate them on appropriate use of the ER, as well as the PCP and clinic after-hours availability. 

Program Results

• Compared to a matched reference group, members who received self-care materials were significantly less likely to visit the ER after receiving the materials. For example, 60 days after receiving the Self-Care book, the percent of members who had an ER visit dropped from 10.5 percent to 8.5 percent.

• On a broader scale, county-wide ER usage decreased by 9.8 percent in first seven months of 2004, compared to 2003 data.

Contact

John P. Monahan, President, State Sponsored Business, 805-384-3511, john.monahan@wellpoint.com