Can ED case management provide cost-effective care at your hospital?
ED case managers help avoid denials on admission, aid discharge
As case management has matured, so has the scope of case management opportunities. While few hospitals have yet extended their case management system into the emergency department (ED), some hospitals now have a case manager assigned exclusively to that department.
A case in point is Saint Vincents Hospital and Medical Center in New York City. Suzanne Greenblatt, RN, MA, the hospital’s ED case manager, says her focus varies from day to day and sometimes from hour to hour, depending upon what she thinks is most important. However, her primary focus is reimbursement, and that means reviewing the initial admission diagnosis prepared by the physician.
Her other immediate concern is the appropriateness of the setting, Greenblatt says. In other words, not every patient must be treated in the ED, and not all patients must be admitted to the hospital.
Greenblatt actually begins discharge planning for the patient in the ED, even though it is not presented as discharge planning, she explains. Not only is that an effective opportunity to meet the family and gather information about the patient, including the patient’s history, but the family and the patient typically appreciate this.
Her position does not include any social work functions. However, she works in conjunction with two social workers who also are dedicated to the ED, Greenblatt says. "That is very helpful," she says. "If somebody comes into the emergency department and they are homeless or they don’t have the resources to buy their medication, I can actually refer the patient to a social worker and concentrate more on true case management issues."
Another hospital that has introduced case management into the ED is Children’s Hospital in Pittsburgh. The model employed there varies because of the pediatric patient population.
Jan Zimmer, RN, CPHQ, director of care coordination at Children’s, says one of the hospital’s strategies is to collaborate with the staff in the ED to identify patients and families who are considered "at risk" and then network with the children’s hospital services internally.
That includes pharmacy, the primary care center, and outside agencies that help facilitate a safe discharge, she says.
Like Greenblatt, she says another immediate consideration is social service involvement. In the ED, history is gathered and Children and Youth Services (CYS) is engaged for possible in-home intervention, Zimmer says.
"Then we provide them information about how to obtain coverage and provide access to prescription and medical equipment and facilitate appointments with the primary care center," she reports.
According to Zimmer, the patient’s family is taken to a quiet area where discharge instructions are provided, sometimes using pictures. Then the hospital financial advisor is contacted to help facilitate state assistance.
From a psychosocial standpoint, certain protocols are followed. For example, social workers must be involved with every child younger than 2 years who has suffered a trauma, says Brett Furlong, a former social worker at the hospital. There also is a child advocacy group made up of trained clinical social workers who assess possible child abuse or sexual abuse.
Using a child advocacy group has taken a burden off the attending physicians. "We are able to follow through with child abuse issues because we have that core group of physicians," Furlong says. "If there is a case to build, they build it."
The hospital also has developed a resource manual for the staff in the ED. "This has been very helpful," Zimmer says. The manual includes operational instructions such as how to arrange for an ambulance transfer. It also explains how to handle patients with Blue Cross insurance and Medicaid HMOs, as well as the steps that are required.
Any staff can follow those steps and arrange for a transfer that insures payment, Zimmer says. The manual also includes specific discharge instruction tools such as if the child is leaving with a nebulizer or other piece of home care equipment, she adds.
Both hospitals agree that coordinating with home care as early as possible can prove very helpful. "Visiting nurses provide eyes in the home for us," Furlong says. "A visiting nurse will report back to us what exactly is going on in the home and what the household conditions are like."
Social workers then can arrange for proper social service follow-up for CYS, which can help establish an effective and safe home care plan, he explains. Many home care agencies will work with the hospital as long as the patient has applied for Medicaid or other assistance, Furlong adds.
Greenblatt agrees that getting home care started within 12 hours of the patient coming to the ED has proven very effective. As the home health market has become more competitive, she says it has become easier to set up those services.
Documenting benefits
According to Greenblatt, many people outside her hospital have asked about the cost-effectiveness of her position. However, some of the information is still anecdotal, she says.
One focus of attention has been to start patients on antibiotics, where appropriate, as soon as the admission diagnosis is made. "That was not always happening," she reports. "Now, I would say that does happen 98% of the time."
What Saint Vincents refers to as the "denial on admission" rate also has gone down significantly, Greenblatt says. That rate refers to cases where a patient’s insurance company decides it is not paying for the admission to the hospital.
Zimmer says her program has yet to employ a database to track activity in the ED, either. "We have a couple of databases we use in the department and have used that on the inpatient side to collect data," she adds. "But we have not done that much on the outpatient side or in the emergency department."
"We are almost finished with our honeymoon period," she adds. While people were initially very excited about having a care coordinator in the ED, she says the expectation was that this would fix all reimbursement issues. However, apart from anecdotal information, only patients who receive home care are actually tracked.
According to Zimmer, one recent initiative in the area of reimbursement is that before any patient is admitted, the admissions registration staff contact Zimmer and review the case so that she can determine if they are putting the patient into inpatient status.
"That is where we are having issues now," she says.
A certain population of patients who routinely visit the ED requires special attention, Greenblatt points out. These typically are called "social admissions," she says, and Saint Vincents has managed to reduce them significantly.
Greenblatt says she works in conjunction with social workers to provide appropriate services because often times, these patients do not require inpatient or ED services.
Often, these patients are elderly and do not have family, she reports. "They may not qualify for a lot of help at home, but with a little bit of help, they might take their medications regularly and not come to the ED routinely with shortness of breath," she explains.
Several years ago, there were so many social admissions at Saint Vincents that patients actually were rotated through all the services, Greenblatt says.
Today, that is the exception, she says.
According to Greenblatt, that is the result of having staff dedicated to setting up services when patients come to the ED rather than automatically admitting them. In some cases, she says, the night staff will keep patients overnight if they think they require assistance at home instead out of safety concerns.
[For more information, contact:
- Suzanne Greenblatt, RN, MA, Emergency Department Case Manager, Saint Vincents Hospital and Medical Center, New York City. Telephone: (212) 604-7000.
- Jan Zimmer, RN, CPHQ, Director of Care Coordination, Children’s Hospital, Pittsburgh. E-mail: [email protected].]
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