Use data to justify adding staff in the ED

Show how case managers affect bottom line

Arm yourself with data before approaching the administration about establishing an emergency department case management department, increasing staff, or changing hours. Determine the peak hours for admissions, and collect data to show the potential savings if case managers are in the emergency department during those hours.

"Case managers have not done a good job in the past documenting and collecting data to substantiate their work," says Brenda Keeling, RN, CPHQ, CPUR, president Patient Response, a Durant, OK, healthcare consulting firm. "Since they don't have data showing what they contribute to the hospital's bottom line, the hospital administrators often don't see the value in adding staff."

In addition to documenting the actual savings, point out to the administration how much time and money the department can save by not having to complete all the paperwork after the fact to make sure the hospital is in compliance. Joanna Malcolm, RN, CCM, BSN, consulting manager, Clinical Advisory Services for Pershing, Yoakley & Associates in Atlanta, says, "If it's a mature case management department that functions well, avoiding doing all the rework could allow you to drop an FTE after you get the emergency department flow going well,"

The case management departments at the four hospitals in Lee Memorial Health System in Fort Myers, FL track emergency department case management interventions and assign a dollar figure to each intervention. The case management directors at each hospital share the data quarterly with hospital administration and with the staff at their regular meetings.

As part of their documentation process, emergency department case managers and social workers access a drop-down menu and check off any intervention that prevents an admission or another emergency department visit, according to Chris Nesheim, RN, MS, CMAC system director, case management at the four-hospital system. The case management software product automatically assigns a dollar figure to each intervention.

The drop-down menu includes items such as clarifying an ambiguous order for observation or inpatient admission; facilitating changing the patient status from inpatient to observation using Condition Code 44 and reducing the potential for a future Recovery Audit Contractors (RACs) denial; changing potential inpatient to observation; finding inpatient criteria for a patient placed in observation; and avoided system funding by identifying alternative resources. It includes observation admission avoided and lists several options including transfer to respite, assisted living facility, or skilled nursing facility; arranging outpatient services; transfer to psychiatric facility; and transfer to low demand/substance abuse unit. Under emergency department visit avoided, the dropdown list includes assist with insurance and coordination of care, assist with MD follow-up visits, and arrange and assist outpatient services.

The case management offices in each hospital produce quarterly reports that tally the interventions by individual staff members, the total monthly intervention in each category, the total money saved in each category, and monthly totals of all interventions and all dollars saved.

Nesheim and her team tweaked their web-based case management software to set up the system and worked with the finance department to come up with an estimate of the financial impact of the intervention. "We tried to be extremely conservative about the savings. When I present the figures to the leadership, I point out that even if the interventions save only half of what we tabulated, the emergency department case manager program still pays for itself," she says.

The health system started the comprehensive tracking system when it restarted the emergency department case management program a year ago. Since it represents an extra step for the case managers, some of the staff remarked that they had to check off interventions that they saw as just part of doing their job. "After the first quarterly report when the case management directors shared the information with their staff, the case managers understood why we were doing it and how much they are saving the healthcare system," Nesheim says.

Malcolm suggests that case management departments start their data collection by compiling the number of times each month when the case manager facilitated changing the patient from observation to inpatient status or from inpatient to observation. Tally the incidences in which the emergency department case manager avoided an inpatient admission by connecting patients with services such as home health or transferring them to a facility that provides a lower level of care. Add up the number of Condition Code 44s the hospital files each month, and emphasize to the administration that this is a red flag to auditors that the hospital has problems getting its admission status right.