Critical Path Network

ED CMs improve throughput as patient advocates

Staff alert them to appropriate cases

When Cooley Dickinson Hospital (CDH) in Northampton, MA, put the first case manager in its emergency department, some of the staff were skeptical about how well the initiative would work, recalls R.F. Conway, MD, medical director of emergency services and chief of emergency medicine.

Now physicians, nurses, and even paramedics routinely alert the case managers when they encounter a patient who could benefit from case management services, he says.

"Emergency department case management is now a tight-knit, well-accepted program that is fully integrated within the culture of the CDH emergency department. We did a short outcomes study when we started the program, but it's been so successful that we haven't found the need to conduct a repeat study. We know that this is a program that works," Conway adds.

Two case managers work in the CDH emergency department Monday through Friday from 9 a.m. to 5:30 p.m. When a complex patient comes in on weekends, the emergency department staff call the case managers who are working the hospital floors.

Their duties range from ensuring that appropriate patients receive the treatment mandated by the core measures to assisting physicians in determining if an admission meets medical necessity or if the admission status is inpatient vs. observation. In addition, the case managers identify community resources that can help patients live safely at home and make follow-up calls to ensure that patients see their primary care physician.

"The emergency department case managers are patient advocates. They go to whatever level is necessary to make sure that the patients receive the treatment they need, have a safe discharge, and obtain follow-up medical care," says Jan Lear, RN, CCM, case management director.

The hospital started its ED case management program in October 1997, after a study showed that a significant number of patients who were being discharged from the emergency department were returning to the ED and being admitted to the hospital because they couldn't take care of themselves at home, weren't seeing a primary care physician, or had other issues that could be alleviated with case management, Conway says.

"We determined at that point that the volume was sufficient to be able to support a case manager in the emergency department. We called around the country and conducted an on-line search, looking for similar programs, but we found that there were no other emergency department case management programs. We collaborated and developed the CDH program from the ground up," Conway says.

A community resource

The case managers are more than just a resource for the hospital. They're a resource for the entire community, Lear adds.

"We frequently get calls from physician offices and people in the community who have questions or concerns about their health care. We do whatever we can to help them," says Christine Plantier, RN, BSN, emergency department case manager.

For instance, family members of elderly patients who want to remain independent have called the ED case managers with questions about what Medicare pays for or how to make arrangements for a community service.

"Our work goes beyond the doors of the emergency department. We link with the community-based physicians, and if we have identified a patient concern, we communicate with them to find a way to resolve it," Plantier says.

For instance, the case manager noted that there were noncompliant patients entering the emergency department with symptoms that indicated that their diabetes was out of control. The case managers collaborated with the patients' community endocrinologist nurse to help the patients manage their disease and obtain medication and supplies.

"Many of these patients are unable to comply because they either do not have insurance or the daily cost of their supplies is prohibitive. Without the appropriate early intervention, an admission to the hospital would be the end result," Plantier says.

When a patient comes into the ED, one of the case managers talks with the patient and family about advance directives, finds out their home situation, initiates consults, and starts identifying their discharge needs.

"The emergency department is the primary entrance to the hospital. We look at our role as the gatekeeper. We have an opportunity to reduce the length of stay by starting the plan of care while the patient is still in the emergency department.

"We collaborate with the health care team to identify if an admission is required vs. a return to their home. When needed, we coordinate community services, such as home care, schedule appointments, and contact their physician's office," Plantier says.

ED holding bed unit

The hospital has created an ED holding bed unit (EDHU) for patients who are being admitted as inpatients or for observation when there is not a bed available on a monitored unit or the medical-surgical floor. The beds are not in a specific location but are designated as a holding bed on a patient-by-patient basis.

When a physician has written the orders to initiate admission and if a bed is not available, the case manager is alerted by monitoring the ED tracking board or receives communication from the charge nurse that there is a patient in the EDHU.

Depending on the patient's admission status, the ED case managers work with the ED nurses to start providing inpatient or observation care.

They initiate the initial case management assessment, identifying the patient's discharge needs and starting the preliminary discharge plan. The ED nurse contacts the case manager and social worker on the unit where the patient will be transferred and discusses the patient's clinical issues, psychosocial concerns if appropriate, and discharge needs, Plantier says.

"It's part of our mission to provide seamless and high-quality care for our patients and to promote a smooth transition to the nursing unit. It is also a great opportunity for us to explain the role of the case manager and to encourage the patient and family members to work with the case managers on the unit to continue to plan for their discharge," Plantier says.

The case managers and the social worker assigned to the ED often are asked to find subacute or long-term care placement for patients who don't meet admission requirements but who are no longer able to care for themselves or their loved ones at home.

"Sometimes a paramedic who transports an elderly patient to the hospital notices that the home is not well maintained or that the spouse may also be in poor health and won't be able to provide care after the patient is discharged," Lear says.

When an elderly patient is at risk, the case managers call Highland Valley Elder Services for a consultation.


When patients can't afford their prescriptions, the case managers tap into community and hospital resources to find a funding source. They may contact a community agency, call local physician offices to get samples, or negotiate a drug with a lower cost and the same clinical efficacy.

"In some cases, they'll call me to find out if we can pay for the medication out of our budget," Lear says.

If a patient has been to the ED several times for a nonemergent condition or is new to the area, the case manager helps him or her find a primary care physician.

The case manager makes follow-up calls after patients are discharged to from the emergency department to ensure that they have gone to their primary care physician for follow up, rather than returning to the emergency department.

(For more information, contact Jan Lear, RN, CCM, at e-mail: