Nurse care managers, new programming aim to provide more outpatient care alternatives for ED patients on the margin
Initiative shifts the focus from ED utilization to admission vs. discharge decisions
The debate raging over whether it is wrong or right for lawmakers to be looking at ways to limit ED utilization may be missing the more important discussion, according to Timothy Peterson, MD, an assistant professor of emergency medicine and medical director for the population health office at the University of Michigan Health System in Ann Arbor, MI. He argues that while the ED is clearly a high-value place for people to receive care, policy makers and emergency providers themselves should be thinking more about the downstream impact that ED physicians have. "We make very expensive decisions for patients. And that admissions vs. discharge decision is one of the most expensive decisions that ED physicians are responsible for," states Peterson.
What’s needed, according to Peterson, is programming and resources so that ED physicians will feel comfortable sending some patients who they now tend to hospitalize home, knowing they will receive the kind of care they need in an outpatient setting. It’s a care model that Peterson and colleagues are planning to have in place within the next six to nine months at the University of Michigan Health System. The process is beginning with the deployment of specially trained nurse care managers throughout the hospital and the ED setting.
First, focus on observation
The ED-based care managers will be tasked with at least assessing every patient who comes through the door, but the degree of intervention is going to vary, explains Peterson. "There are going to be those cases where a patient is clearly going to need to be in the hospital, and their degree of assessment is only going to be to help transition that patient up into the hospital and to set expectations for the admission, length-of-stay, and those sorts of things," he says. "The majority of that work will be handed off to an inpatient care manager."
Similarly, for those patients who are clearly going to be headed home, the intervention by care managers is going to be minimal because these patients will already have discharge plans in place that their physicians are comfortable with, says Peterson.
Where the care managers will have most impact is on those patients who are on the margin. Physicians may be inclined to admit them, observes Peterson, but it will be up to the care managers to help to create outpatient plans that would be equally efficacious and safe for the patients outside of the hospital. "That is where most of their work will be, but we think the absolute number of these patients will be relatively small," he says. "If we can put a resource in place to help physicians feel more comfortable with an outpatient treatment program, where it is appropriate, I think we can have an impact on our readmission rate."
To make such a program work, there has to be what Peterson refers to as a toolbox of alternatives that care managers and physicians can tap into. Already in development is a visiting nurse program from the ED, where patients can get assessment in the home and services delivered to the home, with someone coordinating all of this care with an ED referral, he explains.
"We are also working with some of our skilled nursing facility partners to develop similar programming to help prevent ED admissions," says Peterson. "Fully developing this toolbox is probably going to take another five to seven months. We have to understand what the need is, we have to find partners, and then build those programs out."
Peterson fully anticipates that it will take time for the physicians to become comfortable working with the care managers on cases. "A little bit of tension is going to be natural because we’re going to be taking physicians who are accustomed to a current mode of practice and asking them to think about the difficulty and adjust to a different operation," he says. "We expect some people to have some degree of reservation, but our goal is to put together the clinical programming needed in order for physicians to feel comfortable with alternative treatment plans."
To ease this transition and allow time for the development of effective outpatient treatment options, the care managers will first focus on what Peterson sees as the most straightforward cases: patients who are currently on observation stays. "These patients are defined by payers as folks who don’t need to be in the hospital in the first place," he says. "We think this is the group most amenable to being transitioned out of the hospital and back to home, and receiving the medical care they need in that setting."
Over time, Peterson intends to grow the program to the point where patients with slightly riskier or complicated cases can be safely and comfortably treated at home, but further development of the program will depend on several factors. "On the one hand we have to actually turn on the programming and get the care managers doing the work and assessing the patients, and on the other hand we have to develop that toolbox that we believe people are going to need to be able to tap into," he says. "I don’t believe for a second that ED physicians are admitting people to the hospital for no good reason. They feel there is a lack in the outpatient environment that can’t be met in any other way except by putting the patient in the hospital."
Own the discharge vs. admission decision
Rather than viewing the ED as a high-cost center, policy makers and hospital administrators should, instead, look at how they can better leverage the ED to improve care and potentially reduce readmissions, according to Keith Kocher, MD, assistant professor of emergency medicine in the Department of Emergency Medicine at the University of Michigan Health System. Kocher recently completed a study on hospital and ED utilization among a sampling of 2.4 million Medicare patients who underwent six common surgical procedures over a three-year period. He and his research colleagues found that nearly one in five of these patients had an ED visit within one month of their hospital stay, and more than half of these patients ended up back in the hospital.1
The findings suggest that health care teams need to find better ways to keep surgery patients from experiencing emergencies after they leave the hospital. However, Kocher notes that the data also illustrate the role that EDs can potentially play in preventing readmissions. "You have a huge opportunity to address a lot of the needs that might have caused a patient to feel like they needed to seek out unscheduled care," he observes. "You won’t be able to prevent all readmissions, certainly, and I think it would be unfair to expect that, but you certainly have the opportunity to really try to coordinate some potential alternative plans to readmission."
It is not a matter of putting further pressure on EDs to fix these problems, emphasizes Kocher. "That is not going to get you anywhere meaningful because a lot of these problems are not just clinical," he says. "You are talking about trying to navigate a potentially complex web of social and family concerns."
Improvements at this stage require a system-level perspective and approach to the problem, adds Kocher. "There are certainly going to be lessons that are generalizable and universal, but probably everyone is going to have to struggle with the details of a solution that works in their own environment," he says. "There is not one solution."
Kocher is happy to see care managers being deployed in the ED at the University of Michigan Health System, but he expects a fair amount of trial and error as the intervention is fine-tuned. "I think there is going to be a lot of experimenting going on as far as how to enlist their help. Ideally, you want the care managers to be proactive so it is not the emergency provider who has to constantly generate a discussion or figure out alternatives," he says. "I think it is going to take some time to figure out how best to integrate them into the management of patients, and particularly into the flow of the ED, which is chaotic and time-dependent."
At the same time, emergency physicians need to fully engage in the process, adds Peterson. "If you are thinking about where health care reform is headed on a federal or even a commercial level, we as emergency physicians need to think about owning that admission vs. discharge decision," he says. "The more we can do to begin to shape what that looks like for our patients, I think the more successful we can be. That is really what we are focused on here with this type of program."
- Kocher K, Nallamothu B, Birkmeyer J, Dimick J. Emergency department visits after surgery are common for medicare patients, suggesting opportunities to improve care. Health Affairs 2013;32:1600-1607.
- Keith Kocher, MD, Assistant Professor of Emergency Medicine, Department of Emergency Medicine, University of Michigan Health System, Ann Arbor, MI. E-mail:
- Timothy Peterson, MD, Assistant Professor of Emergency Medicine and Medical Director, Population Health Office, University of Michigan Health System, Ann Arbor, MI. E-mail: firstname.lastname@example.org.