After Hours Care

Little girl and doctorReducing Visits to the Emergency Department

Children covered by Medicaid and CHP+ who do not have a medical home are taken to the emergency department after office hours twice as often as commercially insured children. When you look at the costs for Medicaid patients, it is clear that reducing unnecessary visits to the emergency department or urgent clinic is a major means of reducing the total cost of their care. Studies show that Medicaid families can be successfully helped to change this behavior by providing them with a medical home and after-hours telephone care.

To be certified as a Medicaid Medical Home for Colorado Children and receive the higher reimbursement, your practice is required to provide telephone triage and advice 24 hours a day. Medicaid now reimburses practices for care that is provided outside normal office hours. Click here for our CCHAP Practice Manager Newsletter July 9th, 2014 for the details.

During CCHAP’s pilot phase, after-hours telephone care was provided by Children’s Hospital Colorado After Hours Telephone Care Program (AHTCP) and the practices. Children’s Hospital Colorado ED, Urgent Care Centers and AHTCP have all begun to educate and encourage families on how to access care by telephone instead of going to emergency departments.

Once Medicaid and CHP+ families have been in a private practice for 12 to 18 months, they utilize after-hours telephone care at about the same rate as commercially-insured families. You can anticipate an average of 1-2 calls per night per thousand patients in the practice.

After-Hours Telephone Care

After-hours calls may be handled by the providers (or clinical staff) in the practice or by a telephone triage and advice call center staffed by nurse, mid-level providers or physicians.  Over a 24-hour period, most practices offer a combination. Children’s Hospital Colorado After-Hours Telephone Care Program (AHTCP) is the clinical call center used most often. See below for more information on this service.

Medicaid also provides a no cost Nurse Advice Line that is available to your Medicaid patients for after-hours coverage.  A practice can add this information to their after-hours phone message and meet the minimum requirements of 24×7 accessibility for Medical Home Certification.  Medicaid Nurse Advisor Line 1-800-283-3221

Second Level Triage

Most Colorado pediatric practices assign some or all of their after-hours telephone care to Children’s Hospital Colorado After-Hours Telephone Care Program (AHTCP). Dr. Bart Schmitt and Dr. Steve Poole developed this program, and this system is an excellent resource that provides great advice. However, an AHTCP nurse using the protocols cannot provide telephone triage that is as effective as a primary care provider can. If the AHTC nurse using the AHTCP protocols feels that the child needs to be seen, the practice can opt to have the call forwarded to the on-call provider. The practice provider on call may then find an alternative way to manage the child to avoid an after hours visit. ATCH nurses manage 75-78% of calls without an after-hours visit. Physicians manage 85-90% without an after-hours visit.  We hope in the future that Medicaid will provide incentive payments to practices willing to do second level triage. To learn more about the AHTCP Call Center, please call 720-777-5135.

Additional Methods For Preventing Inappropriate Emergency Department Visits 

Many Medicaid and CHP+ families often have not had much experience with a primary practice with 24-hour telephone availability. They need frequent reminders to call the practice rather than go to the ED. The literature shows that the single best way to reinforce that behavior is for practice staff and providers to:

  • Pleasantly remind parents at every visit that the practice provides 24-hour telephone coverage. Encourage them to call during office hours if they can, but if problems arise after hours, call prior to taking the child in.
  • CCHAP suggests you develop a scripted statement that staff and physicians in your practice will use to encourage families to call rather than just go in. Make that statement a part of every visit. One option is to say: “Don’t forget we are available whenever your child is ill. We prefer you call during office hours, but if a serious concern arises after office hours, please call rather than go to the emergency department.”
  • The next best method is to give them something to take home that reminds them of this practice policy and includes the practice phone number. This physical reminder has to be very difficult to lose – such as a refrigerator magnet.