EXECUTIVE SUMMARY

EDs in the United States handle 136 million visits each year, and as many as one in four of these visits are unnecessary, according to U.S. Department of Health and Human Services (HHS) data.

  • About 12 million ED visits result in hospitalization.
  • Hospitals can reduce unnecessary visits by placing case managers in the ED.
  • The goal is to eliminate ED inefficiency through targeted case management programs that are designed to get patients into the right level of care at the right location.

There are more than 136 million ED visits in the United States each year, and about 12 million of these result in a hospital admission. The average is 43.3 visits per 100 persons, according to data from the CDC’s FastStats. (Data can be viewed at: http://bit.ly/2Ce3rgK.)

Research suggests that as many as one in four ED visits were unnecessary. Those patients could have been treated at a doctor’s office or some other site. These unnecessary visits cost the U.S. healthcare system about $4.4 billion each year, according to 2010 data from the Department of Health and Human Services. (Read more at: http://bit.ly/2QWMOyy.)

Hospitals can help eliminate ED inefficiency with targeted case management programs that have the goal of getting people into the right level of care at the right location, says Diana Cokingtin, MD, medical director, customer service, in Change Healthcare in Nashville, TN.

“Case managers need to be in the emergency department,” Cokingtin says. “They don’t need to be down the hall or two floors up.”

ED case managers can ensure there are nursing homes and behavioral health facilities that will accept patients around the clock for smooth patient transitions.

“We think putting case managers in the emergency department assists hospitals in multiple ways,” she says. “It’s difficult to have case managers in the ED 24/7, but it’s ideal.”

If a hospital cannot staff around-the-clock case management in the ED, another strategy is to create an on-call system so ED staff can contact a case manager at midnight or early in the morning as needed, she adds.

Change Healthcare conducted a study of 1,300 hospitals and found that 65% use case managers in their EDs. (http://bit.ly/2CdSCv9)

“Almost 60% said it ensured they would get the right level of care for patients, and one-third said it ensured the right admissions,” Cokingtin says.

“Another 11% reported it improved documentation,” she adds. “All of these things tell us that having case managers in the emergency department helps reduce denials from insurance companies.”

For instance, the ED case manager can ask physicians questions as they write out orders.

“They can say, ‘You said he failed physical therapy. How did he fail physical therapy? Did he take his meds? Is he getting worse?’” she explains. “Case managers can make sure physicians fill out all of the information that meets the criteria and can teach them proper documentation.”

“Upstreamists” in healthcare are the people who look for the root causes of problems and seek to achieve the triple aim of better care, lower total medical costs, and increased patient satisfaction.

“I heard a talk from someone who said he was an upstreamist, and he felt it was important to learn why patients show up in the emergency department,” Cokingtin says.

In some EDs, the solution is to place a case management team in the ED that includes social workers, pharmacists, and even legal help. Even if the team consists solely of case managers, it can be helpful, she says.

“When you have case managers in the ED, they can help you develop relationships and contracts with other facilities — rehab, substance use, etc.,” she explains. “Then patients can go right there once the contracts are in place.”

For example, an ED patient might be ready for discharge home but need durable medical equipment (DME). If case managers are working in the ED, they could have established a DME contract, making care transition easier, Cokingtin says.

Case managers can facilitate better transfers and transitions by working with a physician advocate in the ED.

“The other big thing is documentation, which is the number one reason why claims are denied by insurance companies,” she says. “If it’s not written down, then the insurance company cannot see that it meets medical criteria.”

ED case managers help doctors learn to improve documentation, she adds.

Best practices strategies can improve efficiency in the ED and throughout the care transitions. Here are several best practice solutions:

• Build relationships. There’s a tendency for hospital staff and payer staff to blame each other for payment problems. Collaboration is a solution, Cokingtin says.

“Collaboration and having a relationship solves problems,” she says.

Case managers can start the collaboration by listing patients who are ED frequent fliers, who usually are admitted, and who will likely see their claims denied, she explains.

The next step is to determine the payers for each person on the list. Then they contact those insurance companies’ case managers, Cokingtin says.

“They say, ‘These patients are a problem for insurance companies and hospitals and emergency departments, so let’s solve it together,’” she says. “Insurance company case managers know these patients, and they can help them meet their needs from a health side so that, hopefully, they won’t come in as often.”

Cokingtin describes an example of the collaboration in action: “We had a case of a patient who came in every Sunday, usually late at night,” she says. “The patient was admitted for heart failure that was getting worse. I told our case manager that we needed to figure out this problem and talk with the patient.”

The case manager sat down with the patient and reviewed everything the patient had done that week. The patient talked about buying pig’s feet and slow-cooking them from Friday to Sunday. On Sunday, the patient would eat the pig’s feet — causing a flare-up of the patient’s heart disease because pig’s feet are so salty, Cokingtin explains.

To find a solution to this pattern, the hospital’s case manager contacted the insurance company’s case manager. Together they came up with a simple remedy: Instruct the patient to take an extra dose of medication and bring the IV meds home, she says.

“Then we contacted another hospital the patient often goes to and spoke with people in their emergency department, telling them the whole story and asking them to give the patient an IV medication if the patient shows up,” Cokingtin says.

“We went upstream to find out what was making the patient’s heart failure worse. We were being detectives, and it’s important that we do this,” she adds. “That’s what you can do with frequent flier patients.”

• Assess denials. Identify physicians who receive the most denials and find out why, Cokingtin suggests.

Often, there is one physician who receives the most denials. The likely causes are documentation or not managing patients’ expectations, she says.

For example, one physician’s practice had a high number of patients sent to the hospital without proper documentation of the reasons. Insurance companies were denying the claims because they didn’t meet criteria, Cokingtin says.

The solution was to have the hospital’s physician advisor review the medical notes, speak with insurers, provide more information, and serve as a liaison about the cases where patients were admitted without adequate documentation, she says.

It was a shared problem, and the insurer and hospital worked together to solve it. “Relationships are so important,” she adds.

• Prevent denials. It can be difficult and frustrating, but hospital staff — including case managers — should discuss cases in which episodes of care might be denied and call payers about them, Cokingtin says.

“It’s nerve-wracking at first when you’re going in there but haven’t talked with those people before,” she says. “But before the denials come in, call some medical director and payer and say, ‘Here’s a unique situation with this patient.’ You can work it out before the denial occurs.”

Putting case managers in the ED also helps with preventing denials because case managers can develop relationships within their facility and with other service providers.

“Having case managers in the ED will make everyone’s life a little easier,” Cokingtin says. “Relationships will be much better for those cases.”