Hospitals need to have case management at every point of entry to ensure patients are placed in the most appropriate level of care, says Mindy Owen, RN, CRRN, CCM, principal owner of Phoenix Healthcare Associates in Coral Springs, FL, and senior consultant for the Center for Case Management.

“Unless hospitals are looking at patient flow and the payment structure beginning at all patient access points, they are missing an opportunity to truly manage the plan of care,” Owen says, adding that the majority of patients are admitted through the ED.

ED case management is essential, Owen says. “Not only do case managers help the medical team determine the appropriate level of care, they determine if the patient is coming to the right facility and the right level of care.”

Sometimes the appropriate level of care is not in the hospital setting, Owen points out. It may be that patients could go home with home health assistance, or have a short stay in a skilled nursing facility, rather than being admitted as an inpatient.

“The emergency department physicians do not have the time or the knowledge of resources to arrange care for patients who don’t need hospitalization. If patients don’t meet inpatient or observation criteria, the case management team can facilitate a transfer to the right level of care,” adds Mark Krivopal, MD, MBA, vice president at GE Healthcare Camden Group in Boston.

“Case managers in the emergency department started out being a nice add-on to have, but now they are incredibly important,” Owen says. She recommends case managers staff the ED at least 16 hours a day, seven days a week, if not 24/7, depending on the activity and the level of the ED.

Case managers have a major and necessary role in EDs, Krivopal states. “Studies have shown that as hospitals expand the hours that care managers cover the emergency department, the number of unnecessary admissions and unneeded observation services go down,” he says.

Many hospitals experience occasional ED bottlenecks that result in patients waiting in the halls until a bed is ready, Krivopal says.

“ED boarding is still an issue. It’s always a chicken or the egg: Is the ED so busy and admitting a lot of people, or are the providers upstairs failing to discharge people early?” he says.

Case managers can help by ensuring patients who are admitted save time for their counterparts on the medical-surgical unit by assessing patients in the ED, identifying discharge needs, and even starting on the discharge plan, Krivopal says.