Critical Path Network
Tom's story: Challenges that ED frequent fliers present
Hospital CMs collaborate with community agencies
A middle-aged male patient — let's call him "Tom" — showed up in the emergency department at Massachusetts General Hospital in Boston about a year ago complaining of pains in his chest and legs.
Tom subsequently made more than 50 ED visits to Massachusetts General alone in 10 months and has been in the emergency department of at least five other Boston hospitals multiple times. He's been a patient numerous times in acute care hospitals, nursing homes, and inpatient psychiatric units all over the state.
"He never stays long. He just walks away. Whether he's admitted to the medical side or to the psychiatric side, he has the right to make the decision to leave, and he does. The cost to the system is huge because he keeps coming back to the emergency department where the staff must, by law, provide evaluation and treatment," says Peter Moran, RN, C, BSN, MS, CCM, emergency department case manager who is working with the Massachusetts General treatment team, Healthcare for the Homeless, and community and state agencies to help keep Tom out of the ED and connect him with the appropriate community resources.
Tom's medical problems include a history of large clots in the lower extremities and pulmonary embolism, along with a schizophrenic affective disorder, Moran reports.
"His medical issues are concerning but he will tell people that he is fine. He can recite every medication he's supposed to be on and an address where he lives, but a lot of it is not true. He knows the system from one end to another and knows how to manipulate the system to get attention," Moran says.
Patients such as Tom present a challenge to case managers because they can never know what is really going on with them, Moran says.
The first few times Tom came into the Massachusetts General ED, the staff had no reason not to believe him when he said he had an apartment but no telephone, Moran says.
Over time, based on his usage of the health care system, Moran began to feel strongly that Tom was homeless.
The staff knew that he had been treated at other EDs because he'd come in with cardiac stickers on his chest from other hospitals all over eastern Massachusetts. In addition, some residents who worked at other emergency departments in Boston as part of their training recognized him from other facilities. A traveling nurse at the hospital knew Tom from working at an ED at a hospital in New York.
Breaking the cycle
"This patient has been using the hospital and emergency department as a home and a support system. I have been working with a multidisciplinary team to develop a plan of care that breaks the cycle," he says.
Most recently, a hospital in northern Massachusetts placed Tom in a nursing home. He walked out after a short stay and is believed to be back in the Boston area.
Tom is disabled and receives disability benefits but since he doesn't have a permanent address and the nursing home he left became the payee, Moran is concerned that he may not be getting his money.
Tom is probably panhandling and relying on soup kitchens for meals, Moran says.
But after months of collaboration between hospitals, community, and government agencies, when Tom shows up again in the ED, there's a plan in place to get Tom the kind of care he needs in a setting that is more cost-effective than the emergency department.
"These kinds of cases are extremely costly. We have been working to come up with a plan to keep him out of the emergency department and get him the care he needs in a more cost-effective setting. There is a whole population of patients who are in this situation and they create a huge cost to the system. It's a fairly small population, but these are heavy utilizers of the health care system and they often fall between the cracks," he says.
When patients such as Tom show up in the ED, staff who have dealt with them over and over are tempted to say, "'It's Tom. He's here again. There's nothing wrong with him,'" Moran says.
"The more I saw Tom, the more I thought he wasn't really having medical problems but I couldn't run the risk of blowing him off when one of his complaints may be real. It's a Catch-22 situation that happens with other patients who make repeat visits to the emergency department," he says.
Tom is a friendly, likeable guy who was depending on the hospital personnel for his social interactions, Moran says. "He'd come to the front desk and the staff would give him money to buy himself coffee and a donut. We realized that we were reinforcing his behavior," he adds.
The Massachusetts General team that has worked with Tom includes social workers, case managers, and a psychiatric clinical nurse specialist who works in the emergency department,
"Enough of us started saying we needed to do something about Tom and were able to bring resources to bear. We tried to develop a care plan to hook him up with primary care in the community," Moran says.
Moran worked with other staff at Massachusetts General to find community case management through the Department of Mental Health or the Medicaid case management program.
"We tried to get a case worker with the Mental Health Homeless Outreach Team to take his case but since Tom said he wasn't homeless, they initially weren't interested in working with him," he says.
The Massachusetts General team was able to make the case that Tom was homeless by collaborating with staff at other hospitals and showing that Tom had been in one ED or another every night for three weeks.
Then, the issue was getting Tom to a place where a homeless outreach worker could conduct an interview. When Tom came to the ED with lower extremity pain, the outreach worker conducted an assessment and concluded that because of medication adherence problems, he could be admitted to a skilled nursing facility or a long-term care facility.
Tom was evaluated by a psychiatrist who determined that he had sufficient insight to make his own decisions, which was not to go to another facility after discharge from the hospital.
"We knew other hospitals had sent him for psychiatric evaluations but they'd always release him. The issue became how to develop a strategy that recognizes his right to make his own decision but that helps him change his decision and manage his own health care," he says.
An involuntary commitment was out of the question because he was capable of making his own decision. The team explored whether they could have a guardian appointed but determined that he was not technically a candidate for a guardianship.
Now that Tom has a case manager in the Department of Mental Health Services, the EDs know who to call when he comes back in.
The plan called for a hospital to discharge Tom to a specific shelter where the homeless outreach worker could check on him on a daily basis, and where Tom could create bonds and develop a relationship.
"If Tom comes in now, he'll be evaluated medically and if he is cleared, we'll try to get him to go to the Pine Street Shelter medical clinic and see the homeless outreach worker stationed there. We are hopeful that the outreach person can create bonds and develop a relationship with him," Moran says.
Tom's story points to the challenges that case managers face in dealing with issues of recidivism in the EDs, particularly with patients who have complex medical and psychosocial needs, Moran says.
The problem is exacerbated when patients are deemed to have the insight and capacity to make their own decisions but are struggling to survive, he adds.
"We do very well if someone falls into one silo, but we have real challenges with cases like this. Emergency department case managers should understand not only the medical and behavioral piece, but the community resource piece, and the financial piece in order to develop a plan of care for patients who are frequent fliers. In addition, we need the skills to mobilize people from many agencies and the time to coordinate resources for them," Moran says.
One issue that impedes dealing with patients such as Tom is getting the information to flow between hospitals and community agencies, Moran points out.
"The challenges are out there. We don't have an integrated medical record that flows with patients, so we're constantly trying to find out what the reality is," he says.
Coordination between facilities and community agencies to develop strategies to address the needs of patients is a very labor-intensive process, Moran points out.
"It's amazing how taxing one case can be. We are fortunate in Boston to have resources but we still don't have a solution for Tom even though a lot of people all over the city are working on it," he says.
(Editor's note: For more information, contact Peter Moran, case manager, Massachusetts General Hospital, Boston, e-mail: [email protected].)
A middle-aged male patient let's call him "Tom" showed up in the emergency department at Massachusetts General Hospital in Boston about a year ago complaining of pains in his chest and legs.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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