Identify areas where a CM can have an impact

Staff the ED at peak hours of admission

It's not necessary to have a case manager in the emergency department 24 hours a day, seven days a week, and case managers don't necessarily have to screen every patient who comes into the ED, says Toni Cesta, RN, FAAN, vice president, patient flow optimization for the North Shore-Long Island Jewish Health System.

She recommends defining those hours in which the ED is busiest and assigning case managers accordingly. Twelve-hour coverage during peak hours should be sufficient.

"I've worked in a lot of hospitals with a tremendous volume in the emergency department, but even there, the number of people coming in the middle of the night didn't warrant having a case manager on duty," she says.

Consider staggering case management hours with the hours that social workers cover the emergency department, she suggests.

Case managers don't have the time to manage the care of all patients who come into the emergency department, adds Peter Moran, RN, C, BSN, MS, CCM, ED case manager at Massachusetts General Hospital in Boston.

For instance, diverting one patient from the ED to another level of care routinely takes four hours, he adds.

"It's not possible to see everyone. Case managers in the emergency department can be pulled in many different directions if you don't set priorities. There must be some mechanism to identify which ones need scrutiny," Moran says.

Patients who are high-priority may be the frail elderly, the homeless, patients who were medically discharged within 30 days, and the hospital's "frequent flyers."

Start by defining the purpose of your ED case management program, what areas the case manager should be expected to affect, and how the program will support the hospital's needs and goals, Moran says.

"Even more importantly, it is necessary to have systems to be able to identify patients who could benefit from case management interventions and a means of documenting the impact of the case management intervention," he says.

In a hospital with high occupancy and an overcrowded emergency department, one goal for ED case managers would be to divert patients to other settings. If the hospital's occupancy typically is low, a goal might be to get the patients admitted quickly.

You might want case managers to concentrate on determining inpatient vs. observation status or to help patients who come to the ED frequently find a primary care physician or other community resources to fill their needs.

"The role of the emergency department case manager depends on the needs of the organization," Moran says.

Once your program is established, set up a mechanism for collecting outcomes data to prove the value of ED case management to the hospital administration.

Cesta suggests collecting outcomes data in the following areas:

  • decrease in denials due to improved patient status or proper documentation;
  • reduction in the amount of time it takes to get patients admitted;
  • reduction in turnaround time for patients who are treated and released;
  • patient satisfaction with their emergency department experience;
  • physician satisfaction with ED case managers;
  • decrease in the number of visits by "frequent fliers"
  • decrease in length of stay due to initiating treatment in the ED;
  • decrease in length of stay due to starting discharge planning in the ED.