ED case managers keep patients from falling through the cracks

Goal is to ensure timely follow-up care

Before Jackson Health System in Miami had case managers in the emergency department (ED), the average waiting time for patients who needed to be seen for follow-up was six months, and only about 22% of patients showed up for their appointments.

As a result, many of the patients who were sent home with a month’s supply of medicine for diabetes, hypertension, or other chronic illnesses, returned to the ED for treatment before their follow-up appointment because they ran out of medicine and their condition became exacerbated.

"One of our main concerns was to reduce recidivism in the emergency room," says Genise Harrelson, RN, BSN, emergency care center case manager. "We recognized that there was a huge problem and one that we needed to focus on. We didn’t want these patients to return to the emergency room because they had no access to health care."

Harrelson is one of three ED case managers at Jackson Health System’s ED in Miami. The first case manager was a registered nurse who primarily collected data but didn’t really have a defined role.

In late 1998, the ED case management model was redesigned, and by mid-1999, there were three case managers — two who deal with the adult population and one who focuses on pediatrics.

"At first, there was a lot of confusion because, within the ED, we had case managers, a social worker, and a patient representative. Nobody really understood who played what role. We worked with the others to develop a referral list, delineating what each professional would handle," Harrelson says.

The case managers also surveyed the ED staff to identify their needs and how case managers could help them work more effectively. The survey helped identify ED case managers’ priorities, roles, and responsibilities.

The case manager’s first priority is to decrease the number of patients who return to the ED repeatedly by improving the method and consistency of referrals from ED services to other services.

"Our mission was to improve the coordination of care when the patient was discharged, making it more appropriate and easier for the patient," Harrelson says.

The case managers communicated their findings to the ED staff and started doing inservices to teach them about the case management role in early 2001. Later on that year, they started meeting with the hospital medical director to address physician and case management issues and get physician input.

The case managers make frequent rounds in the ED, discussing patients with the staff.

Since the trio of case managers schedule appointments for follow-up care and ensure that patients no longer fall through the cracks, waiting time for follow-up is two to four weeks, and compliance with appointments is about 80%.

Jackson Health System is a county hospital affiliated with the University of Miami. More than 90,000 patients a year are treated in the ED. Many of the patients who come to the ED are publicly insured or have no health care coverage.

The hospital operates more than 450 general medical and specialty clinics.

Among the clinics is an ED follow-up clinic that provides primary care follow-up care to patients who are treated in the ED but do not have funding for their health care.

For instance, patients who come in for a broken limb or as a result of an automobile accident and are diagnosed with diabetes or hypertension are followed up at the ED follow-up clinic.

The three case managers are in the ED 13 hours a day, from 6:30 a.m. to 7:30 p.m. They don’t work on weekends or major holidays.

Patients who are discharged when the case managers are not on duty are instructed to call the case managers to set up an appointment.

The case managers originally tried to establish outcomes by looking at recidivism in the ED but found that the information didn’t give the full picture, says Christine Ruschmeyer, RN, BSN, adult ED case manager.

For instance, a patient might come in with out-of-control diabetes and a few weeks later show up with an injury.

Now, they track compliance with follow-up clinic visits as proof that the case management initiatives are making a difference.

"One of our goals is to reduce unnecessary emergency room visits by ensuring that patients get the follow-up care they need. We let them know that keeping an appointment with a doctor helps them avoid another illness and is easier and less time-consuming than sitting in the emergency room," Harrelson says.

The first step the case managers took in 2000 when they established their current ED initiative was to take over setting appointments for follow-up care for ED patients. 

At the time, appointments for follow-up, whether for the ED follow-up clinic or a specialty clinic, were scheduled by the ED secretaries.

The secretaries did not know how to decipher the information as to which HMOs had contracts with the hospital, so they routinely gave every patient a follow-up appointment. The case managers developed an educational letter that is given to HMO patients upon discharge from the ED so they know to get in touch with their providers for the appropriate referral and authorization.

"It wasn’t that we didn’t want to take them or treat them, but since they have HMOs, they have to follow up with their primary care physician," Harrelson says.

The case managers also started routing patients to community clinics affiliated with the hospital that was closer to their homes. Many of them already are going to community clinics for care.

"We get a lot of patients who are not funded or on Medicaid and they don’t have transportation. Coming back to the hospital is a long trip for them. They can walk or take the bus to the community clinics," Harrelson says.

If the patient already has a medical appointment at a community clinic, the case manager prints out the information and gives it to the patient. "In the past, if a patient had an appointment with a doctor in a clinic in two weeks, he still was given a follow-up appointment in six months because the secretaries were not trained to do a thorough screening for existing appointments until the case managers trained them," Harrelson says.

Patients who need comprehensive follow-up, such as a neurological evaluation, a stress test, or a magnetic resonance imaging test, are referred to a hospital specialty clinic for follow-up.

Ruschmeyer coordinates setting appointments for the specialty clinics and makes sure the patient keeps their appointments. 

Patients covered by HMOs or other insurance receive a letter suggesting that they see their primary care physician for follow-up and telling them how to find out who their primary care physician is if they don’t know.

Christopher Chevalier, RN, pediatric ED case manager, follows up on high-risk patients in the ED, working with parents, educating them about the disease process, and stressing the importance of follow-up care.

"I don’t work with parents on every earache or sore throat. I follow up on patients diagnosed with chronic illnesses such as juvenile diabetes, asthma, sickle cell disease, and neurological seizure disorders," he says.

The case managers notify the HMO that the patients are in the ED and give them the required clinical information. If those patients are admitted to the hospital, the ED case managers start giving the HMO patient information up front.

When the patient has a chronic illness, the case managers refer them to the hospital’s disease management classes for diabetes, asthma, congestive heart failure, and other chronic conditions. The classes are available at the hospital and some outlying clinics and are conducted in English, Spanish, and Creole.

"If there is a new-onset diabetic and the doctor wants the patient in a disease management class, I find out when and where the next class is being held and get the patient into that class so he can start learning about his disease," Harrelson says.

Case Management Definition

"Emergency service case management is a dynamic collective process designed to assure timely and appropriate follow-up care to patients presenting for emergency services. Our goal is to increase continuity, quality of care, and decrease recidivism through emergency services."

Source: Jackson Health System, Miami.