Readmission reduction efforts should start in the ED, when patients first come into the hospital and when they make a return visit, says Teresa Marshall, RN, MS, CCM, senior managing consultant for Berkeley Research Group.

A best practice is to have a case manager covering the ED 24 hours a day, seven days a week, Marshall suggests. “Case managers in the emergency department can do a multitude of things, including ensuring patients are in the right status, identifying high-risk patients when they perform an assessment, and avoiding a readmission by intervening with a better plan,” she says.

When case managers conduct an assessment while patients are still in the ED, they have a chance to meet the family and to get a clear picture of the patient’s support system and family dynamics, Marshall says.

Working with the family on a discharge plan is key, Marshall says. “The patient and family have to be empowered and engaged in the discharge plan for it to work. The case management team needs to conduct an in-depth interview to get information that will help in creating the plan,” she says.

ED case managers can help the case managers and social workers on the floor get a head start on planning the discharge, Marshall says. “They can uncover details on the complexity of the patient’s psychosocial issues and any other challenges that could affect the success of the discharge plan,” she says.

For instance, if family members are adamant that the patient won’t go to a nursing home under any circumstance, the case manager on the unit will start looking at alternatives and plan a family meeting earlier in the stay, she says.

The ED is a good place for case managers to learn about language barriers the patient has, Marshall adds. “The hospital staff needs to be able to communicate with patients and family members and to make sure they can understand what is going on,” Marshall says.

Case managers on the floor need detailed information about the patient’s language, cultural beliefs, and practices so they can incorporate them into the discharge plan.

For instance, if a patient who needs home health has a language barrier, the discharge planner should make sure that the home care provider has an appropriate interpreter, she says.

The electronic medical record should alert ED staff when patients present within 30 days of discharge, Marshall says. This should prompt the case manager to huddle with the physician, the nurse, social worker, and the family to determine what went wrong, what the patient needs, if a readmission is indicated, or if there are alternatives to hospitalization.

For instance, patients may be able to go home if the case manager can arrange for a nurse to visit them at home the next day or work with a social worker to facilitate community resources.