Case Management Insider

Roles and functions of ED case manager

The emergency department (ED) case manager has four principal roles that should be observed. Those role are as follows:

Role 1: Gatekeeper.

— Screen all ED patients for appropriateness of admission.

— Determine the appropriate level of care for the patient.

— Offer alternative care settings when appropriate.

— Initiate contact with admitting physician.

— Provide clinical and payer information to MD.

— Ensure documentation matches patient's clinical condition.

In the role of gatekeeper, the case manager provides the first line of defense against inappropriate admissions. Optimally, the case manager should have the opportunity to review potential admissions before they are processed. In other words, once the physician has completed the medical screening exam and wants to admit the patient, the case manager should be the next step in the process and compare the admission against criteria in order to determine whether or not the admission meets acute care criteria.

This process step should become standard operating procedure in the ED for all potential admissions. The buy-in of the medical staff will be critical when implementing this step. The physicians might have concerns that the process will increase the dwell time in the ED. Therefore, this step must be done quickly and efficiently after the patient is identified as a potential admission.

Role 2: Patient flow.

In the role of managing patient flow, the ED case manager performs several important functions. These functions assist in moving the patient through the emergency department continuum of care in an efficient fashion. This process helps to improve ED through-put and also helps to reduce the patient's time spent in the ED, also known as dwell time. The case manager assists in coordinating and facilitating the patient's care. Examples include:

— facilitation of administration of medications;

— coordination and facilitation of tests, treatments, procedures, and consults;

— obtaining records from non-acute providers as needed;

— offering alternatives to admission when appropriate;

— assistance in obtaining an inpatient bed.

Coordinating and facilitating care is a key role of any case manager, and this role is no less true in the emergency department. In addition, the ED case manager should keep the patient informed as to their status and progress. Continuous communication with the patient and family will help to reduce their anxiety and provide them with a more positive experience overall. When delays occur, the case manager can perform an important function by speaking to the patient and family and keeping them informed as to the status of their care and/or bed assignment.

Role 3: Case management assessment.

Once the determination has been made that the patient meets acute care criteria and should be admitted, the ED case manager should complete a case management admission assessment. The assessment is the standard admission assessment used by the entire department throughout the hospital. Each hospital might use a different form, but within the hospital, the same set of questions should be asked regardless of location. For some clinical areas, additional questions might be added as needed.

Some of the benefits of completing the case management assessment in the ED include:

— gathering information from many sources including EMTs, family and friends;

— facilitating the process for the in-patient case manager;

— completing an insurance review if necessary;

— identifying an initial discharge plan.

It is in doing the assessment process that the ED case manager also might determine that an already-admitted patient does not meet inpatient criteria. This situation can happen occasionally when the case manager is unable to see all the admissions before they are processed. If the patient is a Medicare patient, then Condition Code 44 might need to be applied. If not, the case manager will need to work within the polices and procedures of their hospital to cancel or invalidate the admission.

Start Discharge Planning on Admitted Patients

  • Speak with ambulance staff
  • Meet with family / friends
  • Introduce idea of home care or other alternative services
  • Interface with in-patient case managers
  • Check that patient has a primary care physician

Role 4: Reimbursable diagnoses.

The ED case manager can play an important role in ensuring that the documentation initiated in the ED is accurate and complete. If the hospital has a clinical documentation improvement program, then it is important that the ED case manager have a working knowledge of basic terminology to be included in the medical record to ensure accurate documentation, coding, and reimbursement. This information can help as the patient progresses through the hospital stay.

It is common for emergency department physicians to document the admitting diagnosis as signs or symptoms such as abdominal pain, constipation, or dizziness. By working with the physician, the ED case manager can help to ensure that a rule-out diagnosis be documented when the actual diagnosis still is unclear. This step can help ensure that the admitting diagnosis and clinical information given to the third party payer does not result in denied payment. (For other tasks of ED case managers, see story below).

Other important tasks for ED case managers

The case manager should be assigned to the emergency department (ED) as a permanent assignment and not rotated out of the ED. In addition, whenever possible, the case manager should not be someone who is called to the ED when needed. Each of these models provides only limited exposure to the ED patients and relies on others to identify those patients requiring any of the interventions as listed above.

Some of the other interventions include:

— interfacing with community agencies;

— creating plans for high utilization patients;

— referring patients to other/more appropriate hospital areas: direct admission, ambulatory surgery, specialty centers, and elective outpatient procedures;

— monitoring and managing variances.

Examples of community agencies that the case manager might interface with would include home care, senior citizen centers, outpatient day programs, the police department, nursing and adult homes, and protective services. The ED case manager, by interfacing with the community, can help to gather other relevant information that will help formulate the in-patient plan as well as the discharge plan.

High utilization patients—once every 3 months

By Toni Cesta, PhD, RN, FAAN
Senior Vice President
Lutheran Medical Center
Brooklyn, NY

Each hospital must define for itself what frequency of visits to the ED constitutes as high utilization. As a general rule of thumb, high utilization patients are those that visit the ED at least once every three months. You might choose to use a different measure depending on the issues you face in your ED. Once a patient is determined to fall into this category, create a plan to address ways in which to break the pattern of frequent visits and/or admissions.

The plan should be developed with the ED staff and the primary care physician if the patient has one. The plan will be dictated by the issues that are returning the patient to the ED. The patient might need a detox or rehab program. They might be failing in the community and need nursing home placement, or even a group or adult home. In other cases, the patient may be non-compliant with medication administration and might need help obtaining their medications.

Whatever the cause of the patient's visits to the ED, the case manager should work in partnership with the social worker to identify and correct the causes of recidivism.