Critical Path Network

Educating ED staff assures admission criteria

On-call CMs assist with community resources

By educating emergency department supervisors on admissions criteria and community resources, Weatherford Regional Medical Center in Weatherford, TX, has managed to eliminate most social admissions to the hospital and ensure that patients who are admitted meet admission criteria.

"The case managers can't be on duty 24 hours a day, seven days a week. Now we have trained the emergency department supervisors on all shifts so they understand the difference between someone who needs medical care and someone who came to the emergency department because they didn't know where else to turn," says Lyn Clark, RN, BSN, MHA, director of case management.

The 99-bed hospital treats about 33,000 patients a year and has an 11-bed emergency department that is a Level IV trauma center.

The case managers are assigned by floors and are cross-trained so they can handle patients on any floor.

During the week, a case manager is available to the emergency department at peak times and when staff need them. The four case managers and Clark rotate being on call from 5 p.m. to 10 p.m. weekdays and on weekends.

Before Clark began the initiative in June, social admissions were fairly common in the hospital, part of Community Health System, based in Franklin, TN. For instance, people would bring in their elderly parents when they could no longer take care of them and they'd be admitted to the hospital, instead of being transferred to a nursing home.

Social admissions removed

"A lot of social admissions have been removed from the mix. Now the emergency department staff work with the case managers to find an alternative to admission when patients who do not meet admission criteria are discharged from the emergency department; they go to a more appropriate level of care. It's no longer an option to put patients in the hospital overnight and figure it out in the morning," Clark says.

"In the past, patients would be admitted because no one knew what to do with them. With the community resource books, the charge nurses in the emergency department and the case managers can find out what these patients need. If they don't meet admission criteria, they're no longer admitted. It doesn't mean that we don't give them support; we just don't give them support at the inpatient level," Clark says.

Clark created a series of four educational modules for the emergency department supervisors. They include information on the Centers for Medicare & Medicaid Services, definitions such as "case mix index," information on the largest payer sources for the hospital, and the conditions that qualify for observation status under Medicare regulations.

When case managers are called about an admission, they help walk the emergency department supervisor through the process of determining if the patient meets criteria.

"When the ED supervisors call us to talk about an admission, we ask them to put their education to use and tell us what they are thinking about this particular patient. This on-the-job [education] helps them understand the process so they know what to do when the case managers are not in the house," Clark says.

The emergency department staff use criteria sheets to determine if the patient should be admitted or placed in observation status based on lab values and other factors.

Clark emphasizes to the emergency department nurses that she wants them to call if they have questions about patient status or available community resources. "I'd much rather take a phone call and help put patients in an appropriate bed status and avoid having a denial," she says.

The emergency department supervisor can keep the flow of the emergency department moving more effectively and efficiently if he or she knows where to find community resources for patients and whether they meet admission criteria, Clark points out.

"In essence, we have case management services available 24 hours a day because we have trained the emergency department supervisors to function in case management roles," she says.

Physicians were resistant to become involved with the initiative at first but now they appreciate the role the case managers and the emergency department nurses play, Clark says.

"Once the physicians realized that we were there in a supportive and assistive role, they began to value our services. Physicians are not as familiar with community resources as the case managers are. This initiative has reduced the number of inquiries for inappropriate admissions," she says.

Physicians appreciate the help

The physicians also appreciate help determining the patient's admission status, Clark says.

"They aren't going to treat the patients any different due to bed status," she adds.

Clark monitors admissions every day to make sure that admission status is appropriate. If not, she educates the case manager, the emergency department supervisor, and the physician.

"We make sure the hospital is doing the best thing for the patient, and if not, we give the physicians feedback in real time," Clark says.

Clark prepares a monthly education letter for physicians who admit patients to the hospital and meets with the hospitalists almost daily to discuss appropriate admissions.

When the case managers believe a patient has been admitted who does not meet criteria, they discuss the case with their physician advisor who follows up with the admitting physician.

"Doctors just want to practice medicine. They don't realize that if you don't get the right admission status, the hospital won't be paid and the patient may be stuck with the bill," Clark says.

(For more information, contact Lyn Clark, RN, BSN, MHA, director of case management, Weatherford Regional Medical Center; e-mail: