Clinical Basis

It is well documented that patients with multiple comorbidities have higher risk of admission to hospital after ER visit. Identification of these patient and early engagement after discharge has been shown to be an effective strategy to ensure best possible outcomes.

Best Practices

• Identify members seen in ED that meet criteria: 2+conditions prior to visit
  – COPD and Asthma
  – Alzheimer’s Disease and related disorders
  – Chronic Kidney Disease
  – Depression
  – Heart Failure
  – Acute Myocardial Infarction
  – Atrial Fibrillation
  – Stroke and Transient Ischemic Attack

• Schedule any of the included follow up visits within 7 days
  – Outpatient visit
  – Telephone or telehealth visit
  – Transitional care management services
  – Case management
  – Complex Care Management
  – Outpatient or telehealth behavioral health visit
  – Intensive outpatient encounter or partial hospitalization
  – Community mental health center visit
  – Electroconvulsive therapy
  – An observation visit

Important Note: This measure applies to emergency room visits only. If patient is admitted to the hospital, this measure does not apply.

¹ Verhaegh, K. J., MacNeil-Vroomen, J. L., Eslami, S., Geerlings, S. E., de Rooij, S. E., & Buurman, B. M. (2014). Transitional care interventions prevent hospital readmissions for adults with chronic illnesses. Health Affairs, 33(9), 1531–1539. https://doi.org/10.1377/hlthaff.2014.0160