Preventable Emergency Visits Tip Sheet
The rate of preventable emergency (ED) and urgent visits per 1,000 members per year. This measure is derived from the Statewide Collaborative Quality Improvement Project: Reducing Avoidable Emergency Room Visits.
Incentives will be paid on an annual basis, following the end of quarter 4. For additional information refer to the 2021 CBI Technical Specifications.
Members are frequently seen at the ED or urgent care for screening services and general examinations. Below is a list of common preventable ED and urgent care diagnoses derived from the Statewide Collaborative Quality Improvement Project: Reducing Avoidable Emergency Room Visits.
- Acute bronchitis, nasopharyngitis, upper respiratory infection, pharyngitis
- Sore mouth or throat (e.g., thrush, tonsillitis), ear infections
- Allergies, sinusitis, conjunctivitis
- Back pain
- Skin problems/infections (scabies, miliaria, tinea corporis)
- Urinary tract infection
*For a full list of preventable diagnoses, see Preventable Emergency Visits Diagnosis Tip Sheet on the website and the 2021 CBI Technical Specifications.
Note: Change for CBI 2021 urgent care visits will count as half of the value as an ED visit.
Educate All Members To:
- Use the Alliance’s Nurse Advice Line – available to all Alliance members 24 hours a day, 7 days a week, 365 days a year.
- Always call the PCP office for an appointment before going to the ED or urgent care.
Assign Clinic Staff To:
- Monitor the Provider Portal Linked Member ED Visit report as a tool for tracking linked members who were recently seen in the ED, as well as the Linked Member High ED Utilizers for members seen in the ED three or more times within a 90-day period.
- Contact members seen for preventable ED or urgent care visits and bring them in for follow-up.
- Review day-of-the-week trends and open additional appointment times based on trends.
- Look at your third next available appointment times; if appointments are too far out, patients are more likely to use the ED.
- Route after hours calls for Alliance members to the Alliance’s Nurse Advice Line: 1 (844) 971-8907.
- Identify high utilizers of the ED and bring them in to review their problem list.
- Refer Alliance Members to Care Management Services, including Complex Case Management and Care Coordination, by calling Case Management at (800) 700-3874 ext. 5512.
- Refer patients that have transportation challenges to the Alliance’s Transportation Coordinator at 1-800-700-3874 ext. 5577; this service is not covered for non-medical locations or appointments that are not medically necessary.