Discharge Planning Advisor: DP, CM skills may stem bed-capacity problems

Crowded EDs said to be draining resources

The nation’s beleaguered emergency departments (ED) may be just the most visible evidence of a complicated web of problems that is pushing to the limit hospitals’ ability to meet the demands of patient care and presenting new challenges for discharge planners and case managers.

Solutions to those problems may be found in a stronger discharge planning and case management presence in the ED and a more proactive approach to community-based case management, leaders in the field tell Discharge Planning Advisor.

Bed capacity is "higher than anybody anticipated," observes Jackie Birmingham, RN, MS, a longtime case manager who is now managing director of professional services for Curaspan Inc. Because there is no room for patients, they must remain in the ED longer, she adds.

ED diversions — where ambulances are redirected from one hospital to another — are now a year-round problem rather than a product of winter flu season, according to a report by the Wash-ington, DC-based Center for Studying Health System Change (CSHSC). These ED overflows, the report notes, are one symptom of the high-capacity rates in acute-care hospitals.

Contributing to this ED convergence are several factors, Birmingham adds. "Medicare is decreasing payments to physicians, who, as a result, are refusing to take new Medicare patients. Patients who cannot get appointments with primary care physicians, in turn, are increasingly going to the ED for primary care, she says.

HMO disenrollments result in increased ED use

At the same time, elderly patients are disenrolling from managed care plans, or those plans are loosening their control over health care usage patterns, she notes. As a result of these less-restrictive HMO management practices — a response to the consumer backlash against managed care — ED use is increasing, according to the CSHSC report.

Hospitals, meanwhile, have reduced inpatient capacity over the past several years in anticipation of lower utilization under managed care and declining reimbursement from private payers and Medicare, Birmingham adds. Contributing to the problem, she points out, is the nation’s nursing shortage.

What should hospitals do to calm this ED tempest? "The advice is to put more resources into the ED and see what it can do for bed-capacity issues and denials for appropriateness of care," Birmingham suggests. When it comes to discharge planning, in many cases, the players are in the nursing units when they should be in the ED, she says.

With the ED emerging as the center of a "very complex wheel" of patient care events, the question for discharge planners becomes, "Why aren’t you covering the ED 24/7?" Birmingham asks. "Any on-site liaison from an insurance company should sit in the ED, stop by the ED."

Post-acute affected

Actions taken, or not taken, in the ED affect not only the inpatient side of care but the post-acute side, she says.

"I did some consulting at one hospital where there was a bad problem with inappropriate admissions," Birmingham says. After looking at a week’s worth of admissions to observation status, she noticed that most of those admissions happened at 11 p.m.

The bed manager worked until 10 p.m., and the ED physicians — employees of a private company, as is often the case — wanted to clear out the ED for the next shift, she explains. "The ED physicians would admit the patients under observation status, since they don’t have to meet the criteria for true inpatient admission."

The hospital’s discharge planners — as they tried to place these patients in nursing homes or rehabilitation facilities — would find that because they hadn’t met the payer requirement of three inpatient days, the patients were financially responsible for their care at the post-acute institutions, she notes.

"I was at one hospital where the discharge planners weren’t aware that three days’ meant three inpatient days." Hospitals need to have nurses who do case management and discharge planning in the ED, Birmingham advises, if not 24 hours a day, "certainly 12."

Start planning in the ED

Although a great percentage of admissions come through the ED, the focus should not just be on bed placement, she says, but on "how not to admit the patient in the first place."

If patients are admitted to observation status, there should be extremely tight follow-up on their status, Birmingham says.

"They shouldn’t be put into a general population of discharge planning patients." It’s not enough anymore to begin looking at discharge planning on the day of admission, she says.

"You need to start it before, particularly in an ED situation. "A Medicare patient who comes in for primary care may look like he can’t make it at home, but he can’t meet the criteria for admission. You need to refer him from the ED to home care."

It’s an access issue

When looking at the reasons why patients end up in the ED, it’s important to ask the question, "What is their access to health care in general?" suggests Lynne S. Nemeth, RN, MS, director for outcomes management, research, and development at the Medical University of South Carolina in Charleston. "Do they have resources? Do they have established relationships with primary care physicians? Are they being served effectively?"

What Nemeth terms "frequent flyers" — those who regularly come to the ED for treatment — tend to be people with chronic conditions, most often a "cluster" of chronic conditions, she says.

"These are patients with, for example, diabetes with heart disease, high blood pressure, and maybe renal disease. They have multiple comorbidities and are frequently seen in the ED for medical care not being provided through traditional channels," Nemeth explains.

These are people who need community-based case management but don’t get it because the payer system "is not truly converted to support case management in the community," she says.

"For example, in case management in home care or for insurance companies, everybody is protecting resources or limiting access to health care," she points out. "On the other hand, if you take a look at the needs of these patients, they are on complex medications that they may not be able to afford, and they may be scrimping in certain places — taking one pill every other day, for example. As a result, their medical care is often fragmented."

The patients may or may not be homebound, Nemeth notes, but in either case, they tend to be lacking in home care or other community-based resources. "That becomes a part of the component of why they end up in the ED in the first place."

She says the first step in providing a solution is to proactively identify these patients who are "falling through the cracks," who for whatever reasons are not hooked up with community resources.

Although she agrees that case management in the ED is necessary, Nemeth says there may be more proactive remedies. "I supervise a group of case managers who are overseeing hospital patients. If they get involved with all the callbacks they need to make, there is not enough time to take care of those patients who are here today. Even an ED case manager would have that problem."

Looking at a coordinated-care model

What Nemeth suggests is a "coordinated-care model." The Centers for Medicare & Medicaid Services (CMS), she notes, is considering a coordinated care benefit. "CMS has put out an RFP [request for proposal] for a research project and is looking at the idea of making a recommendation for a coordinated-care benefit at the national level."

Eligibility for the benefit would be based upon having five chronic conditions, Nemeth explains, quoting from a report developed at the conference, "to be determined taking into consideration multiple providers, high costs, and high use of services, or a combination of clinically complex chronic conditions amenable to coordinated care, or two or more chronic conditions and functional impairments, which limit the ability of the individual to manage those chronic conditions."

The idea of a coordinated-care benefit, developed by CMS in March at a national conference, indicates that "it is being recognized that chronically ill patients use services more," Nemeth says. "My premise is that’s what happening in the ED, where the case manager might get caught up in episodic Band-Aid work, taking care of a system that’s broken."

While the focus is on setting up a visit with the primary care physician and putting in an order for medications and home care, she adds, these patients need much more.

"They have chronic conditions that limit functional ability, and that hasn’t been recognized and supported well enough through the Medicare program."

"[Medicare] needs to put in that coordinated care benefit so we can decompress the ED as being the hub of care," Nemeth notes. Until that happens, she says, there will continue to be frequent denials for appropriateness of care.

"The ED physician just doesn’t know how to deal with the psychosocial and chronic illness care dimensions," she says.

"If patients seem to lack resources and it doesn’t appear safe for them to go home, they end up getting admitted and it has an impact on bed capacity," Nemeth adds.

For discharge planners and case managers who must deal with the effects of ED overcrowding, Nemeth says, her suggestion is to "analyze your pattern of readmissions to evaluate who is being seen frequently. That gives you an idea of who to focus on."

At her facility, she adds, the reasons for readmission are coded so that case managers can understand the patterns. "The purpose of analysis is to identify the social and system issues that are amenable to being dealt with."

Medical issues are legitimate reasons for ED visits, Nemeth notes, so the question regarding each admission is, "Is it appropriate or because of unmet social or external system needs?"

Once the needs are identified, she suggests, hospitals should develop case management resources to meet them, whether it be follow-up telephone calls or working with primary care physicians to design disease management clinics.

[For more information, contact:

  • Jackie Birmingham, RN, MS, Managing Director of Professional Services, Curaspan Inc., Needham, MA. E-mail: jbirmingham@curaspan.com.
  • Lynne Nemeth, RN, MS, Director for Outcomes Management, Research, and Development, Medical University of South Carolina, Charleston. E-mail: nemethl@musc.edu.

For more information on the CMS idea for a coordinated care benefit, go to www.medicareadvocacy.org/CoordinatedCare.htm.

To read the Center for Studying Health System Change Issue Brief No. 38 on ED diversions, go to www.hschange.com/CONTENT/312/.]