All Entries Tagged With: "Ed case management"
The ED case manager plays a key role regardless of patient status
Every hospital should have a case management presence in the emergency department (ED). Regardless of whether the ED determines the patient’s admission status to be inpatient or outpatient, the case manager plays a large role in ensuring that the patient receives the appropriate level of care and assistance for overcoming any social or financial barriers.
Inpatient
If the patient meets inpatient criteria, the case manager works with the interdisciplinary team to ensure that the care is timely and appropriate. The case manager also begins to create a discharge plan. Remember, discharge planning needs to begin as soon as the patient enters your organization. Most patients want to get medical care, feel better, and go back to their pre-hospitalization life as quickly as possible. The case manager completes a social and financial assessment for all patients to identify any issues that will impede the appropriate discharge plan and/or keep the patient from receiving the appropriate care after discharge. The case manager communicates the goals of the discharge plan to the team members so that they can implement it as soon as the patient is ready for discharge.
Observation
If the patient is assigned observation status in the ED, it is the case manager’s job to explain observation to the patient and/or family. The patient needs to understand that observation is an outpatient service where the physician believes he or she needs more time (up to 23 hours) to determine if the patient requires inpatient admission. The physicians and nurses will continually monitor the patient’s condition and determine if further testing and/or treatment is needed. The case manager also works with the hospital business office so he or she can explain how the patient’s healthcare benefits will reimburse observation services.
Lower level of care
If the ED team determines that the patient needs a lower level of care such as skilled nursing, home healthcare, assisted living, or other outpatient services, the ED case manager works with the ED staff to correctly place the patient. The case management team must establish relationships with community resources so case managers can identify the available resources and complete the appropriate processes.
All of the above assessments are performed within a 12-hour case management shift. Does your organization have ED case managers? Does your organization provide the resources necessary to appropriately provide the right level of care to all who enter your organization?
Is H1N1 hype clogging your ED?
Is it a cold or something worse?
The nightly news is teaming with stories about seemingly healthy young people becoming critically ill from the H1N1 virus, and people are worried.
I am no exception. When I hear a coworker cough of sniffle, I get a little uneasy. I have been able to stay healthy during this young flu season. However, should I find myself running a fever and coughing, my unease might turn to worry. And where do most folks go when they are worried about their health? The doctor, or if they can’t wait for an appointment, the ED.
EDs are crowded as is. The last thing ED staff members need is people presenting to the ED that are afraid their head cold could kill them. That is why Emory University and Microsoft have teamed up to create a the H1N1 (Swine Flu) Response Center.
The H1N1 (Swine Flu) Response Center is a Web-based assessment tool that asks site visitors a series of questions, including:
- Age
- Gender
- Geographic location
- Severity of symptoms
- Length of symptoms
After answering these questions, users receive symptom management advice. In severe cases, the tool instructs users to consult a physician immediately. In less severe scenarios, the tool may instruct users to visit a walk-in clinic or stay in bed and drink fluids.
Site sponsors hope people with less severe symptoms will use this tool’s advice instead of visiting the ED, but is it enough? Some folks might be satisfied by this tool opinion, but others might not trust the advice, after all, there is no better cure for worry than the clinical judgment of a real, live healthcare professional, right.
Tell us about what is going on at your facility. Is your ED crowed with people with flu symptoms, looking for a little reassurance that they are not facing peril? Has your facility developed a system to handle the expected surge in visitors?
ER case managers must have special skills
A nurse case manager is a definite asset in the emergency room (ER). An ER case manager benefits the patients, the staff, and the hospital. The role is multi-faceted and requires superior skills in:
- Quality
- Education
- Communication
- Customer service
- Negotiation
- Creativity
- Risk management
- Knowledge and understanding of insurance requirements and regulatory mandates
It also requires an ability to interact with patients, families, insurance representatives, and caregivers both in the ER and those who are treating the patients in the out-patient arena.
Visits to the ER may have one of several outcomes. Usually, the patient is treated and discharged home with a plan or the patient is admitted to the hospital. It is here that the ER case manager can be most effective to improve the quality of care and prevent readmissions to the ER.
An ER case manager can ensure that each patient who is discharged from the ER has an appropriate discharge plan that is viable and appropriate to assist the patient in recovering and maintaining their health. A case manager is an expert in confirming the patient can afford any prescriptions provided , is able to be compliant with recommended follow-up visits with specialists and can assist the patient in connecting with a primary care physician. The nurse case manager can be instrumental in working with the patient and their support system to make sure that they understand and have the interest and ability to be compliant with the discharge instructions.
The case manager can enhance the care provided by a busy ER nurse and physician by assessing situations and family dynamics, listening to the patient and helping them understand the rationale for various tests and the time needed to interpret results. The case manager can assist the ER nurse with patient education and providing information necessary to maximize the patient’s health status.
The case manager can also benefit the hospital by working with both ER physicians and admitting physicians to ensure that all acute care admissions meet medical necessity and are admitted to the appropriate level of care. The case manager can assist with transfers to alternative levels of care such as skilled nursing or rehab when patients do not meet criteria for acute care but are unsafe to return home. The case manager can arrange home healthcare, physical and occupational therapy or other appropriate services to help a patient maintain their independence in the home.
Case managers are an integral part of the ER team to improve the quality of care and help maintain fiscal responsibility for resources both in the ER and on the hospital admitting units. Case managers coordinate care and provide patients will all the tools necessary to improve their quality of life and feel their best within any limits of their illness or disability.
Determine your facility’s goals for ED case management
The most frequent question I get asked about ED case management is: “Do I need an ED case manager in my institution?” There is no right or wrong answer and what I usually reply is, “what are the issues you are facing and want to address?”
Some potential goals of an ED case management program would be:
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1. Fewer discrepancies between payers and the institution regarding whether an admission should be inpatient or observation status. Clean claims will decrease the amount of time for claims to be paid which can improve revenue flow.
2. Increased referrals to alternative levels of care, resulting in better utilization of inpatient beds, which can also result in avoiding some non-acute admissions.
3. Better communication between the ED, outpatient providers, community providers ,social agencies, families, and payers.
4. Decreased recidivism based on the implementation of certain programs
5. Identification of barriers to adherence to a plan of care such as inability to afford medications, lack of insurance, lack of transportation, etc., and working to address these barriers.
6. Earlier identification of at risk individuals and earlier interventions (i.e., refer to disease management programs, etc.)
7. Assist with arranging expedited follow-up appointments.
8. Early identification and assessment of admitted patients for discharge planning starting in the ED (i.e., identification and early referral to post acute providers, etc.)
9. Improved patient/family satisfaction with the discharge planning process from the ED.
There are many possible goals, but each goal must address the needs of the organization. It is important to define what the goals are and to have a means of measuring the impact of the program.
It would be helpful if people would post information about case management programs at their institutions and include the size of the institution, what the goals of their programs are, the hours of operation, and how it is staffed. There are programs in small hospitals and large organizations and people on this blog come from a variety of settings, so it would be helpful for people to begin to understand how they might be able to operationalize a program. Thanks to all who have contributed to this blog as we can all learn from one another.
What is the main role of the ED case manager?
Hi. My name is Peter Moran and I have been asked to do a monthly blog on emergency department case management. I am currently employed as a ED nurse case manager at Massachusetts General Hospital in Boston and have been in my current position for the past 7 1/2 years. My hope is to allow an avenue for people to pose questions regarding ED case management and share my insights with others as well as gain insight I can incorporate in my daily practice.
I recently received the following inquiry:
What should the main role of the ED RN case manager be? If the hospital you work in does not have a UR team, and the majority of the admissions come through the ED, should the ED CM be solely focused on UR and making sure admissions meet criteria? Just curious of what feedback I will receive.
Thanks, Shannon
