Take steps to fully leverage case managers in the ED
CMs become integral part of the care team
With patient volumes on an upward trajectory and ongoing budgetary pressures forcing ED administrators to stay focused on performance and efficiency, some hospitals are looking for new ways to better leverage the skills of case managers in the emergency setting. The University of Virginia Medical Center (UVAMC) in Charlottesville has taken this tack, and among the benefits are increased capacity and improved patient satisfaction, say administrators. But nearly two years into the new strategy, the hospital is aiming for still higher rewards, and ED leaders believe such gains are possible now that emergency physicians and nurses are on board with having case managers work alongside them as part of the medical care team.
"This has been extremely successful. We are currently staffing one case manager in the ED 12 hours a day, seven days a week, and we have been doing that since the beginning of this project," says Jill Laird-Sanders, RN, MN, NEA-BC, director of Care Management, at the University of Virginia Health System. "We chose 9 a.m. to 9 p.m. because most of the admissions to the hospital from the ED occur between 11 a.m. and 11 p.m., and we wanted to be on the front end of that."
The case managers can’t see every patient who comes through the ED, but they are making rounds and identifying for themselves patients that they can make a difference with, explains Laird-Sanders. "The things they are doing that are helping us as an organization include preventing inappropriate admissions by finding alternative solutions to meet the needs of patients," she says. "At times the case managers are getting prescriptions, getting clinic and specialty appointments established, and there have even been a couple of occasions when they have been able to get nursing home beds procured."
In addition, the case managers are handling home health referrals as well as some level-of-care assessments to make sure that patients meet InterQual criteria for admission, adds Laird-Sanders. "That is not their primary focus, but it is something they have been able to get a good head start on for us," she says.
Select the right people
Getting case managers more involved in the ED was actually part of a larger, hospital-wide improvement effort aimed at improving capacity as well as overall patient flow, explains Becca LaFond, MHA, senior director at Huron Healthcare, a Chicago, IL-based consulting firm that worked with UVAMC on the project. "In terms of the ED being the front of the hospital, the big impetus was to create a better experience for patients so that the ED could be competitive in the market, and to make sure that it was capturing patient volume," she says, noting that patients were waiting longer than they wanted to be seen in the ED, and other hospitals were advertising that they could connect patients to care faster.
When the effort began, there were two case managers working the ED, but their function was really to do back-office, utilization management work, says LaFond. "They did all of their work using computer tools, but did not necessarily engage with the care team, so it was a completely different role than what best practice would be for a case manager anywhere, let alone in the ED," she says.
However, transitioning to the new approach was hardly a simple matter of changing job descriptions. "To put this best-practice role into place, it has to be the right person and right personality," says LaFond.
For instance, she explains that a successful ED-based case manager needs to be able to conduct difficult conversations with patients, families, and even physicians. "What we are finding is that in this current health care environment, a case manager has to have both a working knowledge of the regulation situation, which changes every day, so you have to be able to keep up with that, and then also you have to have the right personality to be able to have strong discussions with some of your health care team who you may see as peers, but they may not see you as a peer," LaFond says.
Such conversations can be difficult, especially in an academic environment, says LaFond, because case managers are not only dealing with the attending physicians, but also with residents and even sometimes medical students, who may not be particularly focused on pertinent regulatory issues. "That is not the number one priority that they are taught in medical school, so they are still learning about this piece of health care and often times a case manager needs to educate them about why she or he is involved, and why regulatory criteria are important," she says. "They are not thinking about the back-end, when denials or readmissions might happen."
The ED-based case manager role is challenging but also crucial, adds LaFond. "I don’t think that hospitals are going to successfully make this move to value-based reimbursements unless they have effective case managers in this type of role," she says. "The role has become very dynamic. It is the type of role where you become a specialist."
Involve stakeholders in planning
The hospital ultimately tapped three nurses to handle the ED case manager role so that they could cover the ED 12 hours a day, seven days a week. "Two of the nurses work three 12-hour shifts per week, and one of them works one 12-hour shift in the ED and then she also picks up some shifts on the inpatient side," explains Laird-Sanders.
It definitely helped that the candidates were not starting out in an unfamiliar environment, Laird-Sanders says. "Two of the ED case managers worked in the ED before so they were known commodities, and the third case manager had not worked in the ED before, but she was experienced on one of the inpatient units, so she knew the environment of the hospital."
Administrators discussed and fine-tuned how the new approach would be implemented for eight months before the case managers were deployed in the ED. "There was a lot of planning, discussing, working with stakeholders, and sharing information," explains Laird-Sanders. "And there was a lot of involvement of the leadership that would be affected."
The hardest part of the implementation was actually getting the staff to appreciate that case management was now going to mean something different than it did six months ago, says LaFond. "A lot of that required individual conversations with physicians and nurses, and getting the case managers out there to meet all of these new people," she says. "It was almost a rebranding of what case management was in the ED, because everyone had prior thoughts about what case management was, and we had to change that culture."
While there was some initial resistance to the approach, it dissolved quickly, Laird-Sanders says. "As soon as the physicians and nurses saw the positive benefits, it stopped being an issue at all," she says. "In fact, if a case manager is sick and we don’t have a replacement, we hear about that. Where is the case manager today?’"
One strength of the UVA model is that it has dedicated case managers in the ED, says LaFond. "I have been to hospitals where they rotate case managers through the ED, and although that is better than nothing, I would say the ideal is this model where you have a few FTEs [full time employee] who really get to the know the ED space really well, and that is what they specialize in," she says. "They develop those relationships with the ED physicians, they get to really understand the inpatient criteria, and they come to know all those resources that are out there in the community. That is not something that you can expect 25 people in a department to all learn."
According to a report that Huron prepared about the implementation of case managers in the ED at UVAMC, the approach helped to lower medically unnecessary length-of-stay by 34 minutes, and this freed up enough capacity for the hospital to treat up to 4,000 additional patients per year.
Address frequent utilizers
Patricia Higgins, RN, MBA, the ED director at UVAMC, did not come to work at the facility until after the case managers were deployed, but she says they are now an integral part of ED operations. "Many times we don’t even think of them as being case managers. They are just members of our team who are there to help support what is happening on a daily basis," she says. "They are the go-to persons if you need to get a patient into the system. They are the people who lead the way to do that, and they can free you up so you can move on to something else."
At UVA, the physicians and the shift managers run flow rounds, but the case managers are in attendance so that they can follow-up on clinic appointments or other arrangements that need to be made before dispositions can occur, explains Higgins. "Also, if a nurse or a physician has a patient who needs resources that are beyond [the scope of the] ED, then they will seek out the case manager for help," she says. "They are right out there in the thick of things. That is where their real office is, and so people feel very comfortable going to them with issues or concerns."
The hospital does not yet have any official data to share regarding the impact of having case managers more integrally involved in the ED, but Laird-Sanders says they are preventing several inappropriate admissions per week, and they have also begun to tackle the issue of frequent utilizers. "The case managers have started to establish relationships with patients and to anticipate why patients are coming to the ED," she explains. "In some cases, they are able to address the situation before a patient even makes it to the door. We have one patient the case managers are calling twice a week just to check on, and that is preventing her from coming to the ED for a non-medical reason."
In the coming months, the hospital plans to address frequent utilizers in a more comprehensive fashion, making full use of the case managers. "We will be looking at this case by case, and working with an interdisciplinary team to establish a plan for these individuals who are using the ED for non-urgent medical needs," explains Laird-Sanders. "That is our next step. We have identified this as a real opportunity to improve."
The hospital is also planning to expand coverage by case managers in the ED so that they are available on a 24/7 basis. "The impact has been so positive that we are looking at how to deal with the FTEs, and we will have to post, hire, and train, so it will be another six months before we can roll that out," says Laird-Sanders. "But that is a decision that has already been made at the higher levels of the organization based upon the effects we have seen so far."
- Patricia Higgins, RN, MBA, Director, Emergency Department, University of Virginia Medical Center, Charlottesville, VA. E-mail: firstname.lastname@example.org.
- Becca LaFond, MHA, Senior Director, Huron Healthcare, Chicago, IL. E-mail: email@example.com.
- Jill Laird-Sanders, RN, MN, NEA-BC, Director, Care Management, University of Virginia Health System. E-mail: firstname.lastname@example.org.