CM experts: Hospitals need ED case managers now more than ever

Expertise needed for medical necessity, intervening with frequent users

These days, if hospitals don't have case managers in the emergency department, especially during peak hours, they run the risk of losing reimbursement as well as having their facility inundated with repeat users who don't have the resources to manage their healthcare in the community.

"Case management in the emergency department came late to the table because for a lot of years, having a social worker was more immediately helpful for crises and psychiatric patients. But now, most hospitals have realized the advantages of adding an RN case manager in the emergency department," says Karen Zander, RN, MS, CMAC, FAAN, principal and co-owner of The Center for Case Management in Wellesley, MA.

The Centers for Medicare & Medicaid Services' Recovery Audit Program put emergency department case management on the map, Zander points out. "It's now clear to most hospital administrators that emergency departments require clinicians who have the kind of expertise needed to work closely with the treatment team, and to evaluate whether patients meet medical necessity criteria and are placed in the proper status, but emergency department case managers can do a lot more than just advise physicians about the correct patient status," she says.

There's a tremendous need for case managers and discharge planners, not just for patients who are admitted to the hospital but also for patients who are treated and discharged from the emergency department, says Jay Kaplan, MD, FACEP, director of service and operational excellence for CEP America, based in Emeryville, CA, and a member of the board of directors of the American College of Emergency Physicians. "Case managers can play a key role in transition of care from the emergency department to the community because no other clinical service interfaces with more members the community," he says.

Social workers also are critical in the emergency department to determine if patients' psychosocial needs are driving their emergency department visits, adds Beverly Cunningham, RN, MS, vice president, clinical performance improvement at Medical City Dallas Hospital.

The number of social workers and case managers staffing an emergency department depends on the types of patients the hospital treats, she says. For instance, hospitals where a large percentage of emergency department patients are Medicaid beneficiaries, chronically ill, or are uninsured may need more social workers than case managers, while it may be a different story at hospitals that treat only a small percentage of patients with Medicaid, she adds.

Case managers in the emergency department can provide essential services to benefit the hospital as well as patients. They can assist physicians in deciding whether patients should be admitted or receive observation services. They can do discharge planning after patients are treated and discharged if they need post-discharge services such as home health visits, durable medical equipment, or follow-up care. They can help steer patients who have non-emergent needs to a more appropriate level of care after they are triaged. They can intervene with frequent utilizers and help them access community resources that can help them stay out of the hospital.

At some hospitals, off-site RN case managers are remotely reviewing the electronic medical records and assisting physicians with determining whether patients meet admission criteria and determining level of care, Cunningham adds.

At Medical City Dallas Hospital, RN case managers who work at home with remote access to the hospital electronic medical record work with the emergency department physicians to determine the patient status and level of care on admission. The hospital also has emergency department case managers who cover the clinical decision unit and work with physicians when more information is needed to determine if the patient meets admission criteria.

The hospital started using the remote case managers to cover weekends two years ago but expanded the program to cover 24 hours a day, seven days a week.

"For the initial review, the off-site case manager reviews the documentation to determine if the medical record supports the patient status. The off-site reviewers do not need to see the patients for this step in the utilization process," says Pat Wilson, RN, BSN, MBA, director of case management.

When patients are registered in the emergency department, it shows up on the system board that is part of the electronic medical record and the remote case manager is alerted that the patient is in the house.

"They can see everything they need to review the record and work with the physician over the telephone while the decision is being made by the physician to admit patients or begin observation services," Wilson says.

The remote case managers send a daily report by e-mail to the hospital-based case managers, letting them know what happened with the patients and what still needs to be done as part of the hand-off communication. In addition, the emergency department case manager sends a work list to the remote case manager.

The hospital contracts with an external physician advisor to review cases for admission criteria whenever appropriate.

It's to the hospital's advantage to have a nurse case manager in the emergency department to set up post-acute care for patients who need it after being treated, and to help patients with non-emergent conditions obtain care at a primary care facility, adds B.K. Kizziar, RN-BC, CCM, CLP, owner of BK & Associates, a Southlake, TX, consulting firm specializing in hospital case management.

Often patients return to the emergency department for the same problem within a short period of time because they didn't get the follow-up care or other services they needed to help them manage their healthcare at home, she points out.

The emergency department staff are trying to process patients so quickly, they don't really have the time or the expertise to connect patients with post-discharge services, but social workers and case managers do, she adds.

High utilizers are challenging for hospitals, and many facilities have ways of identifying them and intervening, Cunningham says. Case managers should be in the emergency department to develop a plan for high utilizers so that whenever they show up at the emergency department, unless they present with something new and different, the staff have a plan in place for connecting the patients with the services they need.

"There's a tremendous return on investment when patients have a care plan identified whenever high utilizers present at the emergency department. This cuts down on the amount of time hospital staff have to spend finding resources for the patient," she says.

Determine the criteria for frequent users at your hospital and once they are identified, work with the emergency department physician to develop a care plan. Enter the care plan into your electronic system and set it up so that whenever the patient registers, the plan prints out so the emergency department staff are aware of it. The staff should call in the emergency department case manager or social worker to get involved, depending on the patients' issues and needs.

After the visit, the case manager or social worker should update the care plan and make a follow-up call to the patient.

Many hospitals are building urgent care centers to keep patients out of the emergency department and free up the emergency staff to treat patients who really need care, Cunningham says.

"There is no requirement in EMTALA to treat a patient who is stable. However, all patients must be screened to determine their stability. Many hospitals are beginning to conduct an initial screening and then telling the patient their condition is stable and giving them the choice of going to a primary care provider or staying in the emergency department to be treated and paying for the service," Cunningham says. Many hospitals have a resource book that lists free clinics and other community resources as well as financial counselors to work with patients to see if they meet the criteria for a government payer.

"When patients come in and it's not an emergency, case managers can walk them to a clinic if there's one on-site or help them get an appointment with a primary care provider," Kizziar says. If you triage patients, determine that it's not an emergency, and refer them to a primary care site, it's not a violation of the Emergency Medical Treatment and Labor Act (EMTALA), she points out. "Hospitals have to get over the fear that everybody who presents has to be treated. You can triage them and refer them to a more appropriate setting," she says.

To continue to stay solvent, hospitals also need to start collecting co-pays up front from people who come into the emergency department, Kizziar says. Primary care providers collect co-pays, and there's no reason hospitals shouldn't do the same, she says.

"Care in the emergency department is not an entitlement, contrary to what many people believe. We have to cover the cost of care, and for that reason, we have to collect co-pays and determine how to approach people without insurance to make some kind of payment," she says.

Keep in mind the old saying "no margin, no mission" and remember that if hospitals don't make money, they'll close their doors. "Hospitals are going broke and closing. Many hospitals are operating in the red. When community hospitals close, people won't have anywhere to go for services," she says.


It takes data to justify ED case management

Demonstrate a good ROI for case managers

If you want to develop an emergency department case management program or add to the one you already have, you've got to collect hard data to show that the additional staff will benefit the hospital's bottom line.

Hospitals today are experiencing a severe financial squeeze, which means case managers have to prove their value and demonstrate a good return on investment to justify adding staff in the emergency department, says Jay Kaplan, MD, FACEP, director of service and operational excellence for CEP America, based in Emeryville, CA, and a member of the board of directors of the American College of Emergency Physicians.

"If case management directors can demonstrate that their hospital is losing money in the emergency department and case managers can affect it positively, the financial people will listen to your argument," adds B.K. Kizziar, RN-BC, CCM, CLP, owner of BK & Associates, a Southlake, TX, consulting firm specializing in hospital case management.

This means collecting data, creating detailed reports, and presenting them to the hospital administration including the chief operating officer and the chief financial officer, Kizziar adds. It takes data to demonstrate the value of having case managers in the emergency department, Kizziar points out. "You can't make the case with anecdotal data," she says.

"The bottom line is, people who make decisions about whether to hire staff for the emergency department are financial people, and case managers need to speak to them in a language they understand, and that's dollars," Kizziar says.

Track how much money the hospital is losing on avoidable admissions through the emergency department, whether the patients were social admissions or didn't meet medical necessity criteria, suggests Beverly Cunningham, RN, MS, vice president, clinical performance improvement at Medical City Dallas Hospital. Typically, avoidable admissions are one- and two-day stays, she adds.

Document how many patients admitted through the emergency department were later changed to observation status or did not even meet observation criteria and determine how much money was lost on these patients, Cunningham says.

Determine how many patients come into the emergency department who are not considered a true emergency and how they are triaged. If they are treated in the emergency department, add up how much money the hospital loses if they don't have insurance or if the emergency department doesn't collect their co-pay, Kizziar says.

Tally the number of frequent users who have chronic disease and use the emergency room to manage their conditions. Look at how many patients who come to the emergency department are back within a week or two with the same complaint and how many of them could have benefitted from being referred to community resources.

Kaplan suggests implementing a pilot project to demonstrate case management savings. Start by identifying a group of patients who are frequent users and getting case management involved in specific interventions for these patients. "If you can show decreased utilization and decreased cost, it demonstrates the value of case management interventions," he says.

Track the decrease in the number of the patients who return to the emergency department within 72 hours and the decreased 30-day medical admission rate for patients treated and discharged from the emergency department.

Look at how many patients are being admitted in a 24-hour period and what times the admissions occur and use that information to determine when a case manager can be the most effective, Kizziar says.

Before you approach management, come up with a specific plan, she adds. Show the potential savings that case managers in the emergency department could generate as well as a specific plan for utilizing the new staff.