By Melinda Young
Case managers in the ED can perform more than utilization reviews. In a newer model for their role, case managers can help put ED patients in touch with resources, helping them avoid readmissions and improve outcomes.
For instance, Cleveland Clinic realized that with the changing landscape of healthcare, there is a way care management can put patients in touch with the community services they need to stay out of the hospital and ED, says Nicole Berman, MSN, RN, CCM, nurse case manager and nursing manager for the care management department of Cleveland Clinic Akron General Hospital.
“We have care managers in the ER, along with social workers,” Berman says. “We try to get those initial assessments done, especially on those patients who end up being admitted.” The goal is to start a transition plan as soon as possible, she adds.
Case managers help patients with whatever they will need when they are well enough to leave. “It used to be called discharge planning, but that’s frowned upon in our culture because that means the patient leaves here, and then we’re done,” Berman says. “We’re looking at transitioning the person to the next level of care and seeing what we can set up for this patient now that we can hand off the patient to the ambulatory setting.”
Placing case managers in the ED setting for transition planning requires a change in culture to look at transitions instead of discharges, she notes. Using the Situation, Background, Assessment, Recommendation (SBAR) handoff method, ED case managers review patients’ needs, including home care referrals, Meals on Wheels, or other healthcare and community services, she says.
This does not mean that ED case managers always can finish what they start. It is difficult to complete transitions when patients are there only for a few hours. But they can start the transition process and reach out to a home care nurse and explain what is being set up and what the patient needs, Berman explains. “It takes some trial and error — some experience,” she says.
ED case managers can invite hospice, service providers, and community-based organizations to staff meetings, where these leaders can describe their services and what is available for potential ED patients.
“If patients meet the criteria and have need for short-term skilled nursing facility [SNF] placement, then some patients might go straight from the ED to a skilled nursing facility,” Berman says. It is challenging for case managers to keep up with SNF bed availability and insurance coverage information, so it is important for ED case managers to stay in contact with skilled nursing providers, she notes.
ED case managers also can stay in close contact with case managers from physician practices and other community settings. “If some patients are seen by specific primary groups, we reach back out to them and they tell us what they’ve been working on with patients, and then we can hand off patients back to them,” Berman says. “It provides nice, continuous care for the patient.”
These types of handoffs also work with home care nurses, she adds. “That handoff to the home care nurse is very valuable to us, and we can take it from there and see what we can put together for the patient before they come back home,” Berman says. “We’re very receptive to it.”
Healthcare may be in the age of communication technology, but some of the old methods still work well. “It’s interesting to me, in a time and age of such huge technology, that it’s still talking to someone, picking up a phone, and finding out what’s going on that is easier than trying to find out through a computer,” she says. “We still need a lot of people skills.”
The ED case management program has resulted in smoother handoffs and care continuum, Berman says. In a population of Akron-based patients, Berman reports 72% of cases that went through SBAR wound up following through on the next step in assigned care. “Everything went smoothly for them, and they did well,” Berman says. Of the rest, 17% were not in network, so there was no way of knowing whether they had follow-up care. Eleven percent did not go to their primary care provider for follow-up, but also had not returned to the ED or hospital for observation status, she adds.
“I think it decreases the barriers if patients remain in one healthcare system because everything is accessible through one electronic medical record,” Berman says. “We have several large hospital systems that don’t use the same EMR, but, geographically, they are close. We don’t see all of the history or tests and procedures they’ve done, and neither does the other system see ours. It becomes hard to deliver high-quality, continuous care when you’re missing part of the information,” she explains.
These ED case manager-led handoffs, with or without the help of shared electronic records, can be important in providing continuous care and improving patients’ care quality and outcomes. For example, case managers helped a veteran patient get the medication he needed to fight an infection. Veterans sometimes go back and forth between community hospitals and VA hospitals, Berman notes.
“It’s not always a smooth transition for those patients,” she says. “We had one patient who was discharged with antibiotics for an infection.” The patient took his prescription to a VA clinic, but he was told they could not fill the prescription because they did not have his diagnosis at hand. “He probably took just his prescription with him, and they needed a diagnosis for why he was getting an antibiotic — a record of some infection and that this was diagnosed,” Berman says.
Until ED case managers began performing handoffs with other providers, they were unaware of the VA’s rules on filling prescriptions. “We had done the handoff to the VA social worker for the patient, and we let the social worker know why he was seen,” Berman explains.
The social worker happened to be in the clinic when the patient was turned down for his antibiotic and made a quick call to the case manager to ask for the discharge paperwork that was needed to fill the prescription. “We faxed the discharge paperwork to her, and the social worker got the information while the patient still was there, and it all worked out very well,” Berman says.
Without the handoff and follow-up communication, the patient would have gone home without his medication, maybe waiting days or a week before trying to fill the prescription again. By then, his infection would have worsened, Berman says.
Employing ED case managers and social workers helps the organization work toward its quality improvement goals, she notes.
“We have a culture of continuous improvement, and all of us are trying to look for ways to do things better and to identify gaps for patient safety and care,” Berman says.