STATE OF WASHINGTON
HEALTH CARE AUTHORITY
626 8th Avenue, SE • P.O. Box 45502 • Olympia, Washington 98504-5502
Tuesday, October 02, 2012
As many of you know, Health Care Authority will be implementing a new utilization review
program for Emergency Rooms (ER). This initiative, which was mandated by the Legislature,
will address use of the ER when it is not medically necessary to receive services in an
Emergency Room setting. Below is a list of programs and tools that will help you assist clients in
the proper use of Emergency Room services.
A TOOL TO MANAGE FREQUENT ER USERS AND NARCOTIC ABUSE:
Patients Review and Coordination -- http://hrsa.dshs.wa.gov/prr/index.htm
Patient Review and Coordination is a health and safety program to assist Medicaid managed
care and fee-for-service patients avoid inappropriate use of the ER for medical care and
narcotic services. Patients placed in Patient Review and Coordination are assigned one
primary care provider, one pharmacy, and one hospital for all their non-emergency care. For
the last several years we have placed our highest users of the ER in this program. Many of
the patients who use the ER frequently would be better treated in a primary care physician’s
We encourage hospitals and ER physicians to:
o Educate your front desk personnel to flag Patient Review and Coordination clients upon
presentation to the ER and consider appropriate referral of the client to his or her primary
care provider when the emergency room setting is not the setting that is medically
necessary. (Note: The program is listed on the eligibility screens.)
o Make referrals to this program when you see patients seeking inappropriate services.
o Encourage local primary care providers who are treating clients in this program to assist
you in care and treatments by filing treatment plans for those patients.
o Regularly access a list of PRC clients by hospitals on a monthly basis.
CASE MANAGEMENT TOOLS FOR MEDICAID CLIENTS RECEIVING OR
ELIGIBLE FOR LONG TERM CARE SERVICES AND SUPPORTS
LTC Case Management -- http://www.adsa.dshs.wa.gov/Resources/clickmap.htm
Personal care and case management services are available for eligible adults and children
who are living in their own home, community based residential facilities (Adult Family
Homes and Assisted Living) and skilled nursing facilities. Services can be authorized by
Home and Community Services, Division of Developmental Disabilities, or Area Agencies
on Aging. Eligible persons may also be served through home- and community-based waiver
programs such as COPES for adults who require nursing home levels of care. Additional
services provided by the waiver may include: client training, skilled nursing, home-delivered
meals, Personal Emergency Response Systems, home modification, specialized medical
equipment, home health aides, transportation, adult day care, community transition services
and nurse delegation.
We encourage your ER to:
o Connect your ER care managers and our case managers by using the Area Agencies on
Aging to assist adults (60 and older) in locating an appropriate medical home for primary
care through Senior Information & Assistance.
http://www.aasa.dshs.wa.gov/Resources/clickmap.htm (click on a county to find the
contact information for Senior Information and Assistance county offices).
o Connect your care managers and our case managers for clients over 18 in need of
personal care services.
o Contact your local Home & Community Service Office for Medicaid eligibility
o Connect your care managers and our case managers for other persons needing care. If the
client is an adult living with a developmental disability, see the Division of
Developmental Disabilities Local Offices for the phone number and location of the
nearest local office or DDD Services for a list of services that may be available.
KNOW WHAT HAPPENS IN ANOTHER EMERGENCY ROOM
Emergency Department Information Exchange (EDIE) -- http://www.ediecareplan.com/
The Emergency Department Information Exchange (EDIE) is another program to help you
manage clients who use ER services inappropriately. The EDIE is an internet-delivered
service that enables care providers to better identify and treat high users and special needs
patients. EDIE can proactively alert health care providers when patients enter the ER
through different venues -- such as fax, phone, email or integration with a facility’s current
Electronic Medical Records.
We encourage hospitals and ER physicians to:
o Encourage local primary care providers and mental health providers to file a care
management plan to assist you in coordinated care.
o Use EDIE information to enhance your clinical workup. The Health Care Authority is
sharing all of its claims data with EDIE, including information related to the Patient
Review and Coordination program care plan as follows:
The Health Care Authority promotes health and safety for our clients. “(Patient Name) " is
currently in the Patient Review and Coordination (PRC) program, according to Washington
Administrative Code (WAC) 182-501-0135, because of over-use or inappropriate use of medical
services. This client has been restricted to the following providers:
Primary Care Provider Name, Address, Phone
If applicable, Clinic Name, Address, Phone
If this client is seen in your facility, please notify the client’s primary care provider and/or refer the
client back for appropriate follow up and management of care.
If you have any questions or concerns about the client or the Patient Review and Coordination
program, please feel free to contact us at 1-800-562-3022 ext. 15606 or go to the program’s
website at http://hrsa.dshs.wa.gov/PRR/ for more information.
MONITORING NARCOTIC ABUSE
Prescription Monitoring Program (PMP) -- http://www.doh.wa.gov/hsqa/PMP/public.htm
Washington’s Prescription Monitoring Program provides ER and other prescribers a narcotic
monitoring tool to improve patient care. This program allows a practitioner to look for
duplicate prescribing, possible misuse, drug interactions, and other potential concerns. By
having this information available before prescribing or dispensing, practitioners can provide
improved care to their patients. Practitioners and other authorized users will be able to access
the data beginning January 2012.
We encourage ER providers to:
o Integrate this information of cash and plan-paid narcotic prescriptions into your care plan.
o Whenever you note patterns of abuse, work with your local pharmacies and prescribers as
well as the Medicaid program.
Agency Medical Director Guidelines -- http://www.agencymeddirectors.wa.gov/guidelines.asp
Medical treatment guidelines are published as an educational tool for medical providers
caring for patients of state agency programs. State agencies use the guidelines to evaluate
health technologies, including devices, durable medical equipment, procedures, diagnostics
and off-label drug use.
We encourage ER providers to use the following tools found at
o An Opioid Dosing Calculator to determine daily morphine equivalents
o Free Continuing Medical Education that fulfills the new licensing standard
o An Anti-Epileptic Guideline for Neuropathic Pain
o Chronic pain agreement
o Chemical Dependency Treatment referral services -- 24-Hour Referral: 1-800-562-1240
o Case Management for Aging and Disabled -- Providers can access a case manager
through 1-800-422-3263 or http://www.adsa.dshs.wa.gov/Resources/clickmap.htm
Any of these tools may help you decrease inappropriate use of the ER. Working together we can
ensure our clients have safe and appropriate medical care. If you have additional ideas please
Jeffery Thompson, MD, MPH
Chief Medical Officer