ED case managers save $4.5 million

Hospital avoids inappropriate admissions

The case management department at Lee Memorial Health System in Fort Myers, FL, has been able to demonstrate a savings of $4.5 million as a result of having case managers in the emergency department.

The majority of the savings, compiled for fiscal 2010, were generated by ensuring that patients were in the right status — inpatient versus outpatient with observation services — and avoiding unnecessary inpatient admissions by transferring patients to a more appropriate level of care, says Chris Nesheim, RN, MS, CMAC, system director of case management at Lee Memorial. The hospital system collaborates with community resource organizations to develop the safety net needed to divert patients who don't meet inpatient criteria to a more appropriate level of care.

Lee Memorial, one of the largest not-for-profit public hospital systems in Florida, includes four acute-care hospitals and two specialty hospitals with a total of 1,600 acute care beds. The health system experiences nearly 80,000 admissions a year, with 47% of them coming through the emergency department.

The care management department has more than 150 employees with an integrated interdisciplinary team that includes case managers, medical social workers, disease management programs, utilization management, and the hospital system's transfer center that coordinates admissions for patients transferred from other facilities for a higher level of care. Case managers are assigned geographically and by unit.

The emergency department case management program was eliminated in the 2009 budget due to budget cuts and reinstated in fiscal 2010, starting on Oct. 1, 2009. "We found that when we no longer had case managers in the emergency department, we were admitting inappropriate patients because there was no one there to facilitate alternative placements. We had a lot of patients who could not be discharged safely to home and were admitted or put in observation until a case manager could find a placement," Nesheim says. The hospital system also experienced an increase in use of Code 44 and Bill Medicare Outpatient (BMO) billing during the time there were no case managers in the emergency department.

The hospital system originally set up its emergency department case management program in 2001 when an analysis of data showed missed opportunities to get patients in the right status at the point of entry, Medicare recoupment for unnecessary admissions, and patient dissatisfaction. "Within 90 days, the emergency department physicians changed their attitude about the program from 'get these people out of here' to 'we need coverage 24/7,'" Nesheim says.

When the program was discontinued, revenue was impacted because of inappropriate admissions, patient flow stalled, patient satisfaction scores dropped, and the emergency department nursing staff reported being overworked because they were dealing with social issues. The health system administration re-evaluated the situation and re-funded the program for fiscal 2010. Administration approved additional staff to cover the emergency department 12 hours a day Monday through Saturday and eight hours on Sunday. In addition, the system added social workers to cover the emergency department eight hours a day, seven days a week.

Case managers are in the emergency department from 8 a.m. to 8:30 p.m. Monday through Saturday and from 8 a.m. to 5 p.m. on Sunday, with social workers covering the emergency department from 2 p.m. to 10:30 p.m. seven days a week. "We looked at our peak times for admissions in order to place case managers and social workers in the emergency department to screen as many patients as possible," Nesheim says.

Emergency department case managers screen patients to ensure that they meet admission criteria and collaborate with the physicians to ensure that the documentation supports an inpatient admission. The goal is to screen all patients to make sure they meet admission criteria, particularly those with high risk diagnoses for one-day stays such as nausea, chest pain, and transient ischemic accidents. The case managers work with the emergency department physicians to make sure the orders are correct and complete.

The case managers also coordinate community services and facilitate placement for patients who don't meet criteria but cannot be safely discharged. They work with special needs patients to develop a plan for care in an appropriate setting, and they conduct reviews of off-hour non-emergent patients being transferred from another facility.

The social workers in the emergency department counsel and support patients and their significant others; provide bereavement counseling; intervene when the staff has concerns about abuse, neglect, and other ethical issues; coordinate community services; facilitate placement for inappropriate admissions; and arrange transfers to other acute care facilities.

Qualifications for Lee Memorial's emergency department case managers include an emergency department nursing background and/or experience in utilization management or case management, excellent communication skills, strong interpersonal skills, knowledge of community resources, knowledge of disease processes, and "a thick hide," to handle critical and often emotional situations, Nesheim says.

The case managers and social workers assigned to the emergency department underwent four weeks of training that included a week of classroom instruction on topics such as InterQual criteria; Emergency Medical Treatment and Active Labor Act (EMTALA) laws; and advice on dealing with difficult people, community placement, and how to involve patients and families in care planning. They spent time with inpatient case managers, social workers, utilization staff, and emergency department staff to learn their roles, and they made site visits to all of the organizations where patients are referred.


For more information contact:

  • Chris Nesheim, RN, MS, CMAC System Director of Case Management, Lee Memorial Health System, Fort Myers, FL. E-mail: chris.nesheim@leememorial.org.