Care management cuts ED use for pain
Care management cuts ED use for pain
Follow-up care is key to success
Before Kootenai Medical Center in Coeur d'Alene, ID, began its pain care management program, emergency department physicians were spending 36% of their work day seeing patients whose primary complaint was pain, excluding orthopedic patients and those experiencing chest pain. Now the physicians spend about 8% of their work day with pain patients, and emergency department visits for patients in the program have dropped by 77%.
"We started the program because we had a lot of patients visiting the emergency department complaining of pain. We know that giving them medication and turning them loose is not the answer. We determined that we needed to do a better job of follow up care, which in turn frees the emergency department physicians to concentrate on emergent patients," says Bat Masterson, RN, emergency department case management at the 246-bed acute care hospital. The medical center, located in rural northern Idaho, sees 50,000 patients a year in the emergency department.
When the program began, the majority of patients who came to the emergency department with pain complaints were not seeing a primary care physician for follow up. Now about 86% of patients are following up with a primary care physician.
The program aims to reduce repetitive patient visits for chronic pain or pain-related complaints in the emergency department by ensuring that patients receive appropriate and consistent pain treatment. Masterson led a collaborative effort with physicians, nurses, social workers, addiction specialists, and pain specialists serving on the team. The team reviewed the medical records and identified individuals who presented with vague pain complaints or chronic back and leg pain, and a high number of emergency department visits, based on Medicare criteria which defines excessive visits as three in a month or six in a year.
Case managers cover the emergency department 12 hours a day, seven days a week. "Besides approving admissions and assigning status, pain management is a big part of their duties," he says.
The case managers are alerted when patients with an excessive number of visits for pain come into the emergency department. The case managers meet the patients when they are in the emergency department and many times, they see the patient before the doctor does. They find out if the patient is seeing a primary care physician on a regular basis and work with the patient and the physician to develop a care plan.
"Many times, it takes as long as 30 minutes to sort out the situation. The case management interventions help the physicians because they don't have to spend so much time trying to get a good idea of what is going on with the patient," Masterson says.
A key to the program is helping patients learn how to navigate the healthcare system appropriately. Some of the patients are not connected with a medical home, in part because they are eligible for Medicaid and a lot of physicians don't take Medicaid patients. The emergency department case managers help those patients find a physician that will treat them. Others are addicts or drug abusers and are offered the opportunity to participate in a substance abuse program.
"A lot of patients have multiple issues and simply fall out of the system. It's more convenient to come back to the emergency department, particularly if they don't have insurance. Having advocacy within the facility is very important in helping them learn to manage their pain appropriately," he says.
The program calls for non-narcotic pain relief whenever possible and as a standard of care for patients with headaches. "Our basic philosophy is not to add more narcotics. We make sure that patients who are truly experiencing chronic pain get appropriate care and are managed appropriately. Patients with true chronic pain need the skills to deal with it," he says.
The case managers perform functional assessments and educate patients about ergonomics. They refer patients to physical therapists as appropriate/needed. "We help them understand that the answer to their chronic pain is not more narcotics," he says.
The team works closely with primary care physicians in the community to coordinate care for the patients. The community physicians are invited to the team's bi-monthly interdisciplinary meetings where each patient in the program is discussed. "This strategy has been beneficial for the primary care providers as well as shown by the increased number of referrals to the pain care management program by the primary care providers themselves," he says.
The hospital communicates with other hospitals in a 150-mile radius to alert staff when patients are enrolled in the pain care management program. "We don't want our patients to go from emergency department to emergency department in search of drugs," he says.Before Kootenai Medical Center in Coeur d'Alene, ID, began its pain care management program, emergency department physicians were spending 36% of their work day seeing patients whose primary complaint was pain, excluding orthopedic patients and those experiencing chest pain.
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