With auditors from CMS and commercial payers scouring patient records for potential denials, it’s essential to have case managers in the ED to work with physicians to ensure that the patient status and level of care are correct and to make sure physician documentation is detailed and complete, says Karen Zander, RN, MS, CMAC, FAAN, president and chief executive officer for the Center for Case Management.

But they can do so much more, she adds. ED case managers and social workers are needed to arrange for equipment and services for patients who can be discharged to home, develop plans for patients who frequent the ED, ensure that appropriate patients receive services at other levels of care or in the community, and facilitate tests and procedures to improve patient throughput, she says.

The role of case managers in the ED has evolved over time to include far more than just determining patient status, says Patricia Hines, PhD, RN, managing director and care management transformation practice lead with Novia Strategies, a national healthcare consulting firm.

“Case managers have become critical members of the team at all points of access to the hospital. They collaborate with the emergency department physicians on patient status, the best plan of care, and the best level of care. They work with the social workers on patients’ psychosocial issues, assist with setting up community resources, and provide support for family members of patients who are seriously ill or injured,” she says.

Physicians and nurses in the ED often are pressed for time and focus on the emergency at hand, take care of the patient’s immediate needs, then move on to the next patient without looking at the bigger picture, says Toni Cesta, RN, PhD, FAAN, partner and consultant in North Bellmore, NY-based Case Management Concepts.

The ED case manager can fill in the gaps by conducting an assessment of the patient, reviewing the entire patient record and looking for patterns or recurring problem. If patients can be treated at another level of care or need another service, the case manager or social worker can set it up and prevent a hospital admission, she adds.

For instance, Zander points out that elderly people often become debilitated during a hospital stay and it’s in their best interest to help them avoid an admission if at all possible. “Emergency department case managers can identify alternative levels of care and facilitate a transfer, or line up services like home health or housekeeping assistance so they can avoid an acute care stay,” Zander says. She adds that some hospitals have specialized EDs geared specifically to elderly patients. “Emergency personnel in these facilities receive training in geriatrics, and the case managers and social workers use targeted assessment categories such as depression,” Zander says.

Patients may make frequent ED visits as they near the end of life, Cesta says. If there are case managers on hand, they can facilitate hospice referrals, which can improve the patients’ quality of life and reduce hospital mortality statistics, she says.

They can facilitate a palliative care consultation for patients who frequently come in for relief of pain and other symptoms, potentially helping avoid hospitalization as well as reducing ED visits, she adds.

“Patients who visit the emergency department frequently aren’t necessarily experiencing behavioral health issues or seeking drugs. They may be floundering and interpreting their issue as an emergency. These are the kind of patients who need help navigating where to go,” Cesta says. Case managers or social workers can help these patients identify a primary care provider and refer them to community agencies that can help with their psychosocial needs.

ED case managers can assist with patient throughput by ensuring that patients who can be treated at a lower level of care are appropriately admitted to that level of care and by coordinating with the bed control staff when patients are likely to need an inpatient bed.

Preventing readmissions is part of the ED case manager’s role, says Nancy Magee, BSN, MSN, RN, senior consultant for Novia Strategies.

“Most hospitals employ a tracking system that can flag patients based on recent hospital admissions or frequent emergency department visits. Emergency department case managers should be looking at the records of these patients to determine why they are coming back and if the readmission can be avoided,” she says. This could mean adding community services, helping with appointments, finding financial support for prescriptions, or evaluating family support systems, she says.

Cesta suggests that ED case managers conduct a root cause analysis to determine the reason a patient is being readmitted, develop a solution to the problem, and include it in the plan of care.

Many times, patients come back to the hospital after discharge because of pharmacy issues, Cesta point out.

“One of the biggest causes of readmission is patients who don’t take their prescriptions, and in some cases never get them filled. If case managers get them filled before they leave, that increases the probability they will take them,” Cesta says.

Or it could be because of polypharmacy issues, Hines adds. Patients may be taking their old medication as well as medications prescribed in the hospital, or they may be taking drugs that interact with each other. Hines recommends that case managers arrange a pharmacy consultation when recently discharged patients return to the ED.

“Part of the role is to make sure patients are connected to post-acute providers. If emergency department physicians know a patient is going to have a follow-up appointment, they may feel more comfortable discharging the patient. Case managers should make sure the patient will have support at home and that post-acute providers have what they need to care for the patient,” Magee says.