Case Management Insider

The new emergency department: It's not just for admissions anymore

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

Not only is the emergency department (ED) not just for admissions, but it has become a key and strategic element of today's case management departments. A primary route of entry for many patients across the United States, it can make or break a hospital in today's highly audited environment.

Prior to recovery audit contractors (RAC), managed care admission denials, readmission payment reductions, observation service, patient flow, Joint Commission standards, and ED overcrowding, the emergency department was every hospital's source of admissions and, therefore, business. ED physicians were instructed to admit, admit, admit! Empty beds were considered bad for business, and so every admission was a good admission. This situation is no longer the case.

Every admission, or potential admission, must be screened carefully for appropriateness and potential transitional planning when necessary. Administrators must not only count the number of discharges they had, but also the percent of those discharges that resulted in non-payment and/or auditing from a RAC or other regulatory body. Those discharges are suspect and need to be understood.

Between 1997 and 2007, emergency department visits increased by 22 million, or 23% faster that the U.S. population.1 We can speculate as to the reason for this increase, but case managers have known for years that the emergency department was the primary route of entry for many populations of patients. Today, Medicare patients complain that they cannot get an appointment with their physician in rapid fashion, so the emergency department becomes the means of last resort. A Medicaid patient might come to the ED to bypass a long wait in a clinic. Physicians send patients to the emergency department to avoid what they might perceive as cumbersome direct admit processes. Mothers bring their febrile children to the ED in the middle of the night because they have no other choice.

Never has case management been so urgently needed in a clinical setting as it is in today's ED. Early acute care case management models did not give great attention to the emergency department as a route of entry to the hospital. In fact, there was very little incentive to do so. Gatekeeping the emergency department was not considered good business; nor was it considered good politics. If you were one of the brave case managers who tried to implement ED CM in the mid-1990s, you know what I mean. Today, most acute care settings recognize the importance of gatekeeping the access points to the hospital, including the emergency department.


  1. American College of Emergency Physicians, 2011.

Goals of ED Case Management

When evaluating or starting an embedded case management program in the emergency department, the goals should be considered such as:

  • managing and controlling the types of patients approved for admission;
  • providing alternatives to admission when appropriate;
  • ensuring hospital reimbursement.

The emergency department case manager will work primarily with the emergency admissions. However, if you have large numbers of planned, urgent or direct admissions, you also might want to consider staffing the patient access department. If at least 50% of your admissions are via the ED, you will need to staff the ED with RN case managers as well as social workers. If the majority of admissions enter via the ED, then you might not need to staff both areas, but you might need to concentrate primarily on the emergency department.