Compile data to make the case for ED CMs
Compile data to make the case for ED CMs
Plan on staff to cover peak hours, seven days a week
If you want to convince your hospital administration to approve case managers in the emergency department, you have to put together a plan that outlines why doing so would be in the hospital's best interest, suggests Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, and health care consultant and partner in Case Management Concepts LLC.
Make a list of all the ways the ED case managers can benefit the hospital and include the financial impact if it can be quantified, she says. (For a list of ways that ED case managers have an impact, see chart.)
Look at the number of patients who go through the ED, how many are admitted, and what type of admissions criteria they may meet. Look at the patients who are admitted and who met the criteria for observation and vice versa, advises Joyce Evans-Bailey, RN, MBA, consultant with Compirion Healthcare Solutions, a health care consulting firm with headquarters in Elk Grove, WI.
"Since I've been consulting, I've become aware of how much importance financial data play in the game of health care. Case managers may not be aware of the cost of providing care, but putting a dollar value on the money an emergency department case manager could save the hospital is important to justify the position," Bailey says.
Go through your charts and look at your denials to determine how many of those patients came through the ED, suggests Joanna Malcolm, RN, CCM, BSN, consulting manager, clinical advisory services for Pershing, Yoakley & Associates in Atlanta.
"It's likely to be a large number, because a majority of admissions in most hospitals come through the emergency department," Malcolm says.
Point out the ways that a case manager in the emergency department could have prevented the admission and the denial.
Work with the finance department to determine how much reimbursement the hospital lost because of denials for care that could have been avoided if a case manager had intervened in the ED, Cesta adds.
Facing budget constraints
It may be a challenge to get the hospital administration to approve an ED case manager because of hospital budget constraints and the nursing shortage, Bailey points out.
"A lot of hospitals are pushing back their staffing so much that they can barely handle the inpatient case management piece," Malcolm points out.
Look at the load the acute care case managers are carrying and use that to help make your case. If they have a heavy load and a lot of responsibilities, point out to the administration that it's likely to be difficult for them to float down and cover the ED, Malcolm points out.
Use the extra demands on the emergency department's RNs to make your point, Evans-Bailey adds.
"Not only do emergency department nurses have to take care of patients, they also have to work on discharge planning and transferring patients who don't need to be admitted if there's no case manager present," Evans-Bailey says.
One case in point is the increasing number of psychiatric patients who present to the ED, she adds.
"It takes a tremendous amount of time to get these patients transferred to an appropriate facility. Case managers can do this and free up the nurses to take care of patients. Gather information on how many psychiatric transfers the emergency department makes and how long a typical transfer takes," Evans-Bailey says.
Cover EDs at peak times
Hospitals should make it a priority to have a case manager covering the ED at least during peak times, even if they can't cover the ED around the clock, Malcolm says.
In most hospitals, that doesn't mean the typical shift that case managers may prefer to work, she adds.
When case managers work in the ED from 8:30 a.m. to 5 p.m., they miss the bulk of patients who come to the ED, particularly those who tend to overutilize emergency services, Malcolm says.
"It may be a challenge to find people who want to work that 3 p.m. to 11 shift. Covering the emergency department during daytime hours is better than nothing, but it won't take care of the issues that need attention," she adds.
24/7 ED coverage
Some hospitals are looking at having case managers in the ED 24/7 to deal with all the issues that arise, Cesta says.
"I don't think hospitals need case managers around the clock, but they do need them 12 hours a day, seven days a week, during peak volume times. Medicare will allow hospitals to review cases that came in during the night, and if the admissions are not appropriate, they can use Condition Code 44," she explains.
Assess when your peak volume occurs and plan on covering those hours, Cesta says, adding that in most hospitals, the ED volume is highest from noon to midnight.
"This may vary by geographical region. A lot of this goes along with when school gets out or when the doctors' offices are closed," Malcolm adds.
EDs should be staffed with nurse case managers, as well as social workers who can handle all the social issues that arise in today's EDs, such as domestic violence, child abuse, and rape, Cesta says.
Case managers and social workers should work together to discharge patients with psychosocial issues, she adds.
Scheduling CMs, social workers
Hospitals with 30,000 ED visits or fewer per year will need 2.5 FTEs to provide case management in the ED for 12 hours a day, seven days a week, and two FTEs of social workers, who typically work eight hours a day, five days a week, Cesta says.
Cesta suggests having the social workers come in at 8 a.m. to deal with the social issues for patients who came in during the night. Case managers should cover the ED from noon to midnight.
"By assigning the social workers and case managers to different shifts, you can cover the emergency department from 8 a.m. to midnight. That leaves just eight hours without coverage," she says.
Emergency department RNs may be good candidates for the case management job since they are clinically skilled, know how the ED works, and already have rapport with the physicians, Evans-Bailey suggests.
"These nurses may be ready to move into a role that is in their familiar setting but less physically demanding," she says.
If you want to convince your hospital administration to approve case managers in the emergency department, you have to put together a plan that outlines why doing so would be in the hospital's best interest, suggests Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, and health care consultant and partner in Case Management Concepts LLC.Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.