EXECUTIVE SUMMARY

Emergency department case managers are essential to prevent payer denials by ensuring that patient status and level of care is correct; prevent admissions and readmissions by linking patients to community services; improve patient throughput by ensuring that tests are procedures are conducted in a timely manner; and to facilitate hospice and palliative care referrals.

  • Case managers should cover the ED seven days a week during the hours when the volume is highest. Hospitals with a lot of payers that require preauthorization, or a large volume of complex patients, or those with behavioral disorders may need 24-hour coverage.
  • EDs also need social workers on hand to coordinate community services, facilitate mental health referrals, and handle issues such as abuse, neglect, domestic violence, and chemical dependence.
  • The best candidates for ED case management positions are experienced case managers with a high level of clinical knowledge, good organizational skills, and the ability to work quickly.

“Get everything right up front,” is the mantra hospital case managers have been hearing for years. But the only way case managers can ensure that things are right “up front” is to see patients up front, as they are admitted to the hospital.

Since the vast majority of non-elective patients come in through the emergency department (ED), stationing case managers in the ED is a necessity in today’s healthcare environment.

“The emergency department care management team can have a profound impact on their organization’s operations by preventing admissions when patients could be cared for in another setting, improving patient throughput, enhancing patient safety, and increasing patient satisfaction. The role of the emergency department case manager is extremely critical to managing the delivery of care and the next level of care for the patient,” says Patricia Hines, PhD, RN, managing director and care management transformation practice lead with Novia Strategies, a national healthcare consulting firm.

One of the most important reasons for having case managers and social workers in the ED is to determine if patients meet inpatient criteria and to ensure they get to the right level of care. They provide value to the hospitals as well as to patients and families in many other ways, adds Karen Zander, RN, MS, CMAC, FAAN, president and chief executive officer for The Center for Case Management. (For a look at some of the tasks that ED case managers should perform, see related article in this issue.)

Case managers in the ED basically have the same role as their counterparts on the floor — they just need to do the work quickly, says Toni Cesta, RN, PhD, FAAN, partner and consultant in North Bellmore, NY-based Case Management Concepts.

“Emergency department case managers have the responsibility for utilization management, level of care, discharge planning, and facilitating treatments and procedures in a timely manner,” she adds.

ED case managers should focus on patients who have been discharged within 30 days to determine why the patient is coming back and if a readmission can be avoided, Cesta suggests.

Another priority should be patients who don’t have an actual diagnosis, such as patients who complain of abdominal pain or headache. “These are not diagnoses; these are signs and symptoms. Soft diagnoses are what the Recovery Auditors jump on. If the patient record lists only the signs and symptoms, the case managers should ask the physician to list the presumptive diagnosis,” Cesta says.

After the potential readmissions and soft diagnoses, the next priorities for ED case managers is to assess patients who are likely to be admitted, saving time for the case managers on the unit and working with high-utilizing patients to help them access a primary care provider and avoid another visit, Cesta says.

Cesta tells of a patient who came back to the ED complaining of chest pain four times in a short period of time. The case manager in the ED looked at the patient’s lab work and saw that he appeared to be anemic. She got the patient an appointment the next day with a primary care physician who treated the anemia, which, in turn, prevented more ED visits by the patient.

“This is a great example of how emergency department case managers can link the patient with services in the community and avoid a hospital admission. Knowing that the patient had a physician appointment the next day helped the emergency department case managers feel comfortable in discharging the patient. The primary care intervention also prevented more emergency department visits,” she says.

These days, patients who come through the ED tend to be sicker than in the past because many patients with minor complaints and those who can afford to pay go to urgent care facilities if they have medical issues when their physician office is closed, Zander points out.

“Somebody needs to be in the emergency department to coordinate care and discharge services for patients who present with multiple comorbidities and/or psychosocial issues, and that’s where case managers and social workers can be a big asset,” she says.

Hospitals need two disciplines — RN case managers and social workers — in the ED at peak times to cover all the tasks that arise, Zander says. They should be dedicated specifically to the ED and not called down from other places unless it’s a critical access hospital with limited staff, she adds.

Nurses, not social workers, have the expertise to make suggestions on patient status to the admitting physician. Social workers are essential when patients, especially those with behavioral health issues, need other services in the community in order to be safely discharged, Zander points out.

Case managers and social workers should collaborate to ensure that patients get the services they need in the right setting, adds Nancy Magee, BSN, MSN, RN, senior consultant for Novia Strategies.

“Social workers have expertise on community resources such as knowing which homeless shelter has a nurse on staff or which patients qualify for medication assistance. In some cases, they can help patients avoid an admission by setting them up with home health or durable medical equipment, or other community services,” she adds.

Social workers also can provide valuable help for the clinical staff in the ED by addressing issues such as abuse, neglect, domestic violence, and chemical dependency; setting up referrals for patients with psychiatric issues; and educating patients and family members about end-of-life options, Magee says.

Hospitals should staff the ED seven days a week but not necessarily 24 hours a day, Zander says. Instead, she recommends staffing the ED with a case manager and a social worker during the times when the volume is highest. Saturday, Sunday, and Monday are usually the ED’s busiest days, she adds.

“Having care managers work a standard 9 a.m. to 5 p.m. shift Monday through Friday is not effective because that’s not usually when emergency departments have the highest volume,” Magee adds.

Zander advises case management departments to collect data on patient volume and busy times of day and days of the week, and then work with the hospital administration to determine when case managers are really needed.

The number of ED case managers and the hours they work will vary depending on each hospital’s patient population, Cesta says. One rule of thumb to keep in mind is that, on average, case managers can touch about 20 patients in an eight-hour shift in the ED, she says.

Staffing patterns can vary by payer mix and case mix index, Magee adds.

For instance, hospitals with a significant number of payers that require preauthorization for any services may need to staff the emergency department 24/7, she says. Round-the-clock staffing also may be a good idea when a majority of patients have multiple comorbidities, behavioral health issues, or both, Magee adds.

“When the emergency department gets busy, the clinical team will be pressed for time and may have difficulty making the preauthorization telephone calls,” Magee says. “Alternatively, they may treat the immediate problem and not deal with other issues.”

When assigning staff to the ED, case management directors should consider that many EDs are often busiest during off hours and weekends when physician offices and clinics are closed, Hines says. “Hospitals may need more case managers and social workers on the weekends to help with throughput in the emergency department,” she says.

Magee cites guidelines that suggest one FTE case manager for every 20,000 to 30,000 ED visits each year, but adds that there are other factors that influence hospitals’ needs.

“Some large medical centers that have a high volume of patients with behavioral health issues need to have two or three case managers in the emergency department during peak times and staff the emergency department 24/7,” Hines says. Hospitals that have a high volume of behavioral health and substance use disorder patients may find it beneficial to have a separate psychiatric ED, often called a “Crisis Center,” Zander adds.

Smaller hospitals should analyze patients’ arrival times and assign a case manager to the ED at the busiest time of day. One option is to cross-train the nursing supervisor or other clinical staff to handle the duties when a case manager is not in the ED, Magee suggests.

Cesta recommends that RN case managers and social workers cover the ED 18 hours a day. She suggests staggering the shifts of the nurses and social workers, such as having the social worker come in at 8 a.m. and the nurse at 11 a.m.

One hospital Cesta worked with has three nurses and two social workers assigned to the ED. “By staggering their shifts, the emergency department is covered from 8 a.m. to 10 p.m.,” she says.