ED CM facilitates appropriate care level
ED CM facilitates appropriate care level
Program aims to save resources for hospital, patients
As emergency department case manager, Janeice Garrison, RN, MSN, BC, sees herself as the "point guard" for the hospital in a large, mostly rural area where the population is growing by an average of 22.4% a year and the percentage of uninsured, undocumented, and homeless patients is increasing.
"For every patient I can get into an appropriate level of care, I can save resources for the hospital, the community, and the patient," says Garrison, emergency department case manager at Winchester Medical Center, a 411-bed regional medical center with a Level II trauma center. The Virginia facility draws patients from a three-state area.
In 2008, Winchester Medical Center experienced 66,591 emergency department visits. Of these, 75% were discharged to the community and 25% were admitted to the hospital.
The position of emergency department case manager was created in 2004 to ensure that patients who are not admitted to the hospital receive follow-up care and help them navigate the health care system after discharge from the ED.
The hospital's unit-based case management staff rotate through the emergency department to handle medical necessity and admission status issues.
"I take care of the 75% of patients who aren't admitted but who need help with navigating the health care system," Garrison reports.
Garrison is responsible for calling patients after discharge from the emergency department to assist with scheduling outpatient appointments, calling patients with laboratory results and helping them get follow-up appointments, facilitating admissions for alternative levels of care for patients who don't meet acute care criteria, and addressing recidivism rates in the emergency department.
She also collaborates with the hospital's social workers and utilization review staff and assists with transfers or referrals to community resources for patients who don't meet acute care admission criteria.
Garrison collaborates with the case manager on the unit to ensure that patient care is coordinated.
"I try to be the link between inpatient and outpatient care. When a patient is referred to me, I look to see what the in-house case manager has done and work from that. The reverse is true; if I have worked with a patient being admitted, I give a heads up to the case manager and the social worker on the floor," she says.
Like other hospitals, Winchester Medical Center is challenged with capacity issues, long waits in the emergency department, denials for care, and a growing segment of uninsured patients, Garrison reports.
"It's well documented across the country that there are an increasing number of patients who don't have a primary care physician, who don't have insurance, and who have poor adherence to their medication regimen and treatment plan. Many use the emergency room for primary care or don't receive the follow-up care they need. I concentrate on getting patients to the appropriate level of care and helping them access community resources," she explains.
Garrison receives referrals from the emergency department staff and from the hospital's patient advocates, who cover the emergency department 24 hours a day and are on the lookout for patients who need extra assistance.
She has developed a simple referral form with spaces for the name of the person making the referral, the reason for the referral, and the patient label, which gives Garrison the information she needs to access the patient's medical record.
Much of Garrison's communication with patients is via telephone but whenever possible, she sees them in person.
A lot of patients from rural areas come to the emergency department at Winchester because they don't know where to find resources near their home, or they don't know how to apply for them, Garrison says.
When patients appear to use the emergency department as a primary care provider, she tries to get them to see a primary care physician. When they can't afford care, she helps them apply for the hospital's financial assistance program or other community resources.
"I am most successful with patients who want to do something for themselves. There are those patients, however, that I simply cannot help because they just don't want any assistance," Garrison says.
Many of the patients and family members are very appreciative of getting the care and assistance they need, she says.
Garrison contacts all the family practices in the region that Winchester Medical Center services on a quarterly basis and finds out which are taking new patients and what restrictions they have on taking new patients. For instance, many of them will restrict the number of Medicaid or Medicare patients they see.
"We have practices that don't take Medicare or Medicaid patients and those which charge uninsured patients on a sliding scale based on income, but they often have to limit the number of these patients they can see every month," she says.
She keeps up with which practices use physician extenders and offers patients an appointment with a nurse practitioner or a physician assistant if they can't get a physician appointment.
She maintains a relationship with area dental, clinical, and mental health clinics as possible resources for patients who present to the emergency department.
"Basically, I try to keep a handle on what is out there so I can help patients get treatment at the appropriate level of care. For a lot of patients, my main job is being an educator," she says.
For instance, many patients who come to the emergency department with back pain insist on a referral to a neurosurgeon instead of a referral back to their primary care physician.
Often when a doctor orders an MRI and the hospital tries to get preauthorization from the insurer, the procedure is denied if the patient hasn't had 30 days of outpatient treatment.
"This is when the patient is directed back to his primary care physician for continued support and interventions prior to such an expensive test. If a patient needs a neurosurgeon or specialty appointment, I review the case with him and offer referral assistance. These actions are under guidance of the emergency department physician's group," she says.
When patients from the emergency department get prescriptions filled and pharmacists have questions, they contact Garrison.
"Many times, the doctor prescribes a medication that isn't on the patient's insurance company formulary. I go back to the doctors and ask if they could prescribe something else," she says.
The pharmacies like the arrangement because they don't have to wait hours for a physician to return phone calls and the physicians are happy to be freed up from calls from pharmacists, she says.
[For more information, contact: Janeice Garrison, RN, MSN, BC, ED Case Manager, Winchester Medical Center, e-mail: [email protected]; Additional information is available through the AHC Media's webinar series. Learn more at www.hcmconference.com or call (800) 688-2421.]
As emergency department case manager, Janeice Garrison, RN, MSN, BC, sees herself as the "point guard" for the hospital in a large, mostly rural area where the population is growing by an average of 22.4% a year and the percentage of uninsured, undocumented, and homeless patients is increasing.Subscribe Now for Access
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