Intensive CM cuts ED visits, hospitalizations

Team helps patients get access to resources

Community Memorial Hospital's Intensive Case Management Program, which connects frequent emergency department users with appropriate community-based services, has decreased emergency department visits by 42% for a cost savings of $157,769, acute care admissions by 44%, saving $370,475, and reduced the average length of stay by 1.2 days for patients in the program at the 250-bed community hospital in Ventura, CA.

Patients in the program have an average age of 44 and have multiple physical illnesses coupled with substance abuse and mental health issues. Many are disabled and receive Medicare benefits. Some are homeless. "These patients are young and very sick and have multiple comorbidities. If we don't get them set up with services that can help them stay out of the hospital, we will pay the price for years, not to mention the price they will pay for a lower quality of life," says Bonnie Subira, MSW, director of the Intensive Case Management Program.

The hospital team went beyond just labeling patients as frequent users and analyzed why they continued coming to the emergency department and determined that one of the biggest factors was that patients had no continuity in care.

"They were being seen by a different provider every time they came in and nobody put the pieces together. Our intensive care management team helps patients identify needs and gain access to the requisite resources. They continue to work with service providers, both medical and non-medical, to ensure that all care providers are aware of the services being provided to the patient. They are the constant factor in assuring that the patients get access to the care and services that they need," Subira adds.

The hospital's intensive case management coordinators work Monday through Friday, 8 a.m. to 5 p.m. The intensive case management coordinator position is 1.2 FTE and 48 hours a week. The two coordinators each work two days a week, and both work on Wednesday.

"This gives us a chance to brainstorm on any problems we encounter. Having two sets of eyes on a case has been extremely helpful because this is a difficult and frustrating population and we can share ideas," says Sarah Johnston, MSW, MPH, intensive case management coordinator.

They provide care coordination and other support for about 90 patients at a time. Patients are identified by a screening tool that assesses emergency department visits, hospital admissions, pain management and psychosocial issues, medical complexity, and insurance and financial information.

When patients are identified for the program, the coordinators sit down with the patients and develop a plan to help them manage their conditions at home. The coordinators educate the patients on available resources in the community and the importance of seeing their primary care provider. "We go beyond education and do whatever is necessary to ensure that they get the care they need. We set appointments for them, go with them to appointments if necessary and act as their advocate. Nobody wants to be sick, but these people have complicated healthcare issues and they need a lot of support and assistance," Johnston says.

The team identifies patients' needs beyond their medical care, including community resources and mental health resources. "We see how connected or unconnected they are and route them back to the right resources," Johnston says.

When patients in the program present to the emergency department, a flag shows up on their medical record and the intensive case management coordinator is alerted. Their goal is to see patients in the program every time they come into the emergency department. "If they come in during a time when we're not at work, we follow up with telephone calls. If we can't get them by phone, we contact the agencies where they are likely to receive services and get in touch with them that way," Johnston says.

The coordinators go to the emergency department and meet with patients face-to-face, says Carrie Sundberg, LCSW, intensive case management coordinator. "We go over the care plan that we have developed with the patient, talk about why they came to the emergency department, and how they could have avoided the visit," Sundberg says. They review the discharge plan from the patient's previous visit and determine if the patient has followed up on components of the plan and identify any roadblocks to adherence. "Our goal is to partner with our patients in a way that helps them to have better health and an increased quality of life," Sundberg says.

When patients are hospitalized, the intensive case management coordinators visit them in their hospital rooms and work closely with the unit case managers to develop an effective discharge plan. "If the staff on the floor needs additional support working with the patient or managing behavioral issues, they know they can contact us," Sundberg says.

The intensive case management coordinators contact the primary care physicians to find out what has been happening with patients in the community that may have resulted in the hospital admission and share the information with the hospital treatment team. Shortly before discharge, they meet with the patient and work on changing the care plan, and notify the primary care physician about the hospital stay.

When appropriate, the coordinators convene family meetings that may include the primary care providers and specialists. In some cases, they bring in an interpreter. They educate the family members on the importance of filling prescriptions and helping patients adhere to the treatment plan and make them aware of community resources they can access, Sundberg says.

The intensive case management coordinators work with patients for months or even years at a time until their condition stabilizes. Visits with the patients range from as short as 15 minutes to as long as five hours, depending on the patient's needs. In addition to the face-to-face time, the coordinators spend a lot of time collaborating and coordinating with providers and organizations in the community to assure that the patients get the care they need, Sundberg says.

The team reaches beyond the walls of the hospital and has developed good working relationships with community providers as well as religious organizations, public health agencies, mental health providers, housing assistance programs, and organizations that support the homeless, Johnston adds.

"We want to give these patients the best chance they can have as outpatients. It often takes a long time to get the patients stable but we never give up. When we are successful, it's so sweet," Johnston says.


  • Bonnie Subira, MSW, Director of the Intensive Case Management Program, Community Memorial Hospital, Ventura, CA.