ED case managers can improve throughput, reduce denials

Staff should be dedicated to the department

If your hospital doesn't have case managers who are dedicated to the emergency department (ED) and who work during peak hours, you're missing an opportunity to improve patient throughput, reduce denials, and cut down on patients who return to the ED over and over.

Unless there is a dedicated case manager in the ED, the emergency department staff may not contact one at a time when he or she can truly be beneficial, such as determining if a patient meets the level of care for inpatient admission or if the patient could be treated in another level of care, says Lorraine Larrance, BSN, MHSA, CPHQ, CCM, manager with Pershing, Yoakley & Associates, a Charlotte, NC, health care consulting firm.

"In most facilities I visit, the era of emergency department case management has not come fully into its own," Larrance adds.

Most facilities do have inpatient case management staff who can be called when there is a complex patient whose needs are outside the expertise of the ED nursing staff to handle, she says.

"This doesn't fulfill the truly effective role of an emergency department case manager. The emergency department nurses are focused on their scope of work and don't always realize the value of what case managers can lend to them in their management of patients or overall for the organization," she says.

Case managers typically are among the few people in an acute care setting who have extensive knowledge of what happens across the continuum of care and who can make sure that the patient is treated at the appropriate level of care, says Peter Moran, RN, C, BSN, MS, CCM, ED case manager at Massachusetts General Hospital in Boston and president-elect of the Case Management Society of America.

"Case managers can provide a tremendous service in the emergency department by looking beyond the patient's immediate needs. They can help patients and family members learn to navigate the health care system and find the resources they need in the community. They know what criteria must be met for admissions and what documentation needs to be in the chart. They recognize what patients need consultations and what discharge needs are likely to be," Moran says.

Case managers are in a unique position to make sure that patients who are admitted to the hospital qualify for acute care, adds Toni Cesta, PhD, RN, FAAN, vice president, patient flow optimization for the North Shore-Long Island Jewish Health System. Cesta is responsible for patient flow at 15 hospitals in the Great Neck, NY-based system.

"Access-point case management is critical in today's hospitals. Depending on where the majority of patients enter the hospital, a hospital may need case managers in the admitting office as well as the emergency department," she says.

Case managers are knowledgeable about admission criteria and discharge planning and can help physicians determine the appropriate level of care from the beginning, rather than having it determined 12 to 24 hours later on the inpatient unit, Larrance says.

"By the time the inpatient case managers get to the patient and medical record, it may be too late to change patient status, particularly if the patient could have been admitted in observation status," she adds.

Emergency department case managers can have a great impact on patient throughput by working with the ED physicians and nursing staff to get a patient who is borderline for inpatient admission managed in the emergency department and avoiding an unnecessary admission, Larrance says.

Once a physician determines that a patient should be admitted, case managers should be brought into the process before the paperwork is done to make sure that the patient meets criteria and that the diagnosis supports the admitting diagnosis, Cesta says.

Case managers in the ED have an opportunity to affect the patient's length of stay by starting the patient assessment and facilitating the initiation of care, such as getting tests and procedures performed early on and making sure that appropriate patients receive the treatment covered in the core measures, such as antibiotic administration, Cesta says.

"Case managers in the emergency department can get a tremendous amount of good information by talking to the ambulance staff if the patient was picked up from home. They can meet with family and friends in the emergency department and share the information with the inpatient case manager," she adds.

They can talk to patients and family members about what they can expect during hospitalization and begin to talk about discharge options, Moran adds.

For instance, the family may think a short stay means a week and the physician actually means overnight.

If it appears that the patient will need post- discharge services, such as rehabilitation or home care services, ED case managers can start the ball rolling by finding out if the patient has a preference for services and setting up whatever screenings and services are necessary.

If a patient is likely to be discharged to a skilled nursing facility (SNF), the ED case manager can contact the facility and request the screening, rather than waiting for the unit case manager to do so the next day. Sometimes patients can be placed directly from the ED, depending on their needs and contractual agreements, Moran says.

In busy emergency departments like the one at Massachusetts General, case managers can be invaluable in helping place patients in an alternative level of care.

"A lot of times, the patients the case managers are dealing with may be chronically ill, but in terms of who is in the emergency department, they may be some of the healthier patients and can be moved to another level of care," Moran says.

For instance, a Medicare patient who insisted on going home from the hospital instead of spending time in an SNF may come back to the ED in fewer than 30 days. The patient doesn't need acute care but isn't managing at home and can be transferred directly to a SNF after evaluation.

"Case managers need to identify these kinds of patients when they come in and make sure the work-up is done so they can be moved. Keep them on the radar screen for the emergency room physicians, who may be distracted by sicker patients coming in," Moran says.

Moran frequently encounters families who are bringing in their loved ones with dementia or other conditions because they can no longer care for them.

"The families are burning out and desperate for help. The ED case managers can help them access assistance programs, such as elder services, meals on wheels, home health aides, or adult day programs. People don't know how to access these services. Part of the role of the emergency department case manager is to educate them," he says.

Case managers in the ED should review patients who are being transferred from other facilities to determine if their needs can be met at that facility, he adds. For instance, many acute rehab hospitals can treat patients with pneumonia but often transfer them to the acute care hospital for an evaluation. The doctors in the ED see a new pneumonia patient and put them in for a bed in the acute care setting.

"When this happens, I suggest that our emergency department doctor calls the doctor at the facility to see if the problem can't be handled there," Moran says.

Case managers have the opportunity to intervene in the case of patients who keep returning to the ED.

For instance, if a patient comes in with back pain, ED staff conduct an examination and an X-ray and, if there is nothing acute, give the patient pain medication and suggest a visit to a primary care physician. Many times, the patients can't get a doctor's appointment before they run out of pain medicine and return to the ED.

This is an opportunity for the case manager to intervene and get the patient an expedited appointment with the physician or a prescription that will last until they can see the physician. Patients who have additional ED visits seeking pain medicine can be labeled "drug seeking" when in fact they did everything they were instructed to do and the problem is access in the community, Moran says.

ED case managers can help get medication for patients who can't afford it and refer uninsured patients to someone who can help them sign up for public assistance.

"The bottom line is, hypertensive patients need to be sent home with medication, and if they don't have the money to buy them, they may come back when they have a stroke and the hospital's liability is much higher," he says.

Case managers in the ED can monitor variance data, such as delays in getting patients in beds, patients who can't afford medical equipment or medication, or patients whose physician sent them to the ED for what should be an outpatient test or procedure, Cesta says.

"They can identify barriers to care and work to overcome them on a case-by-case basis, then collect aggregated data to look for patterns where process improvement is needed," she says.

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