Case management in the ED isn't a 'luxury' anymore, consultant says
Compliance, financial issues make the gatekeeper role mandatory
In today's health care environment, hospitals are challenged on all fronts. The Recovery Audit Contractors (RACs) are carefully scrutinizing hospital records, looking for inappropriate admissions, incorrect level of care, and inaccurate coding in the charts of Medicare patients.
Hospitals are struggling with reimbursement, compliance, throughput, and customer service issues, none of which can be successfully managed without a case manager in the emergency department, says Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, and health care consultant and partner in Case Management Concepts LLC.
Putting case management in the ED is a 'necessity'
"Having a case manager in the emergency department used to be a luxury. Now that reimbursement issues are more stringent and the RACs are looking at appropriate admissions, putting case management in the emergency department is a necessity if hospitals are going to maximize their reimbursement," says Joyce Evans-Bailey, RN, MBA, consultant with Compirion Healthcare Solutions, a health care consulting firm with headquarters in Elk Grove, WI.
It's no longer enough to have unit-based case managers rotate being on call to deal with social issues in the ED, Cesta points out.
"Today, there are so many other issues that the idea of just sending a case manager to the emergency department when needed doesn't make any sense," Cesta says.
The only thing worse than having an inpatient case manager on call to cover the emergency department would be to ignore the emergency department patients altogether, adds Joanna Malcolm, RN, CCM, BSN, consulting manager, clinical advisory services for Pershing, Yoakley & Associates in Atlanta.
Impact of RACs
"Inpatient case managers already have multiple responsibilities. They have too much else on their plate to have to run down to the emergency department to assess those patients. In most hospitals, the emergency departments are not close to the inpatient floors," Malcolm says.
During the three-year RAC demonstration project, the auditors concentrated on medically unnecessary admissions and zeroed in on one-day stays.
Since the majority of hospital admissions come through the emergency department, it makes sense to have case managers located there to act as gatekeepers and ensure that patients who are admitted meet criteria and are placed in the proper bed with the proper status, Cesta says.
"In the past, the majority of admissions denials that could be quantified came from managed care. Now, with the RACs scrutinizing admissions data, hospitals can also quantify savings when they avoid a Medicare denial. Managed care and Medicare are most hospitals' two biggest payer groups, and it doesn't make sense not to take a proactive approach to avoiding denials from them," Cesta says.
Building rapport with ED staff
It's important for case managers to be physically present in the ED so they can build rapport with the physicians and nursing staff who can alert them to patients who might have admission or discharge issues, adds Kimberly Gilbert, RN, case management consultant, clinical advisory services for Pershing, Yoakley & Associates.
"Having case managers in the emergency department is a great benefit for staff because they start to look to the case manager as a person they can depend on and go to for guidance regarding the patient's discharge needs and other issues that may arise," she says.
The primary goal of emergency department case managers is to screen patients for criteria to be admitted to the hospital or criteria for observation services. They should make sure that patients are admitted in the appropriate status and to the appropriate level of care, according to Gilbert.
"It's critical to have patients admitted in the correct status so the hospital can bill appropriately for whatever services the patient receives. Case managers in the emergency department can make sure the status is correct and the patient meets criteria to be in the hospital before they are admitted," Gilbert adds.
When case managers are in the ED, they can conduct utilization review assessments before admission and determine who can be discharged with home care and who can be appropriately admitted, as well as who is appropriate for observation services, Cesta adds.
In some states, the case manager is empowered by the "admit by case management protocol," which is used to determine the appropriate level of care, she points out.
More typically, case managers review the cases and have a conversation with the admitting physician if they don't meet criteria.
"The case managers do the legwork for the doctors, but the physician ultimately has the authority to make the admission decision," Cesta says.
Missing out on revenue
In addition to admitting inappropriate patients and not being reimbursed for their care, hospitals are missing out on revenue by not admitting appropriate patients who present in the ED, Malcolm says.
"A lot of times, people look at emergency department case managers as just being gatekeepers who keep everybody out. That's not the intention, and it's not the appropriate use of emergency department case managers. They also should be looking for appropriate admissions," Malcolm says.
Case managers can identify "frequent fliers," who continue to come back to the ED because they have not received the level of service they need. The case managers then can assist the physicians and staff to ensure that the patients get the services they need so they don't keep bouncing back, she adds.
"Sometimes patients are treated and sent home when they might meet admission criteria. They come back the next day or the next because their condition is worse. By the time they're finally admitted, they're very sick," Malcolm says.
"The emergency department case manager role, as I see it, is someone who can collaborate with the emergency department RNs and collaborate on finding the best place for the patient. They can affect quality of care for the patient, as well as reimbursement," Evans-Bailey says.
Benefits of ED CMs
For instance, case managers can ensure that admitted patients being held in the ED are provided the same level of care as other admitted patients and can play a part in helping facilitate the transition to an inpatient bed, Cesta says.
"They also can ensure that appropriate care for the admitted patients is initiated in the emergency department rather than waiting until they are in a bed on the unit. This starts their treatment earlier and reduces overall length of stay," Cesta says.
ED case managers have the opportunity to start the discharge plan at the point of admission, Malcolm points out.
"Sometimes the only opportunity a case manager has to see the family, especially of an elderly patient, is in the emergency department. They can find out the patient's living conditions at home, family support, and other information that the acute care case managers will need to complete the discharge plan," she says.
By ensuring that patients who are admitted meet admission criteria and that they are in the correct level of care, ED case managers improve throughput, alleviate capacity issues, and prevent ED diversion, Cesta says.
From a financial and patient flow standpoint, hospitals should run at about a 90% occupancy rate, she notes.
"Ensuring that patients get to the right level of care and in the right bed is part of capacity management, and case managers can help improve that," Cesta says.
CMs good resource for other ED staff
Case managers in the ED can be a good resource for the nurses and physicians, Gilbert points out.
"When case managers are in the emergency department, they can answer questions about discharge and head off social issues. They can provide resources for patients to move out of the emergency department quickly," she adds.
For instance, a case manager dedicated to the emergency department can arrange home health services for a patient while he or she is waiting for discharge papers. If the case manager has other duties and has to be paged, the patient may have to wait an hour or longer until the case manager can come down and address the issue.
Not all case management functions are directly related to cost savings but may help with cost avoidance, compliance, and patient satisfaction, Cesta adds.
When case managers review patient charts in the ED, they assist the physicians with documenting everything appropriately, Malcolm says.
"They may see a lot of clinical indicators in the chart but notice that the physician documentation is lacking. They can communicate with the physician to add documentation at the time of admission, rather than someone else having to find the physician later," Cesta says.
For instance, if a patient comes in with exacerbated chronic obstructive pulmonary disorder and also has chronic renal failure, the case managers can make sure that the information is documented fully in the chart.
"In addition to assuring that patients meet criteria and that they are in the proper status, they can also make sure the documentation is there to support all the services the patient will receive," Malcolm says.
ED case managers also can play a role in ensuring that appropriate patients receive the care recommended in the core measures and that it is documented in the chart. They can make sure that conditions that are present on admission are documented in the chart so the hospital won't lose reimbursement down the road.
They can make sure that the patient and family are aware of what is going on and feel like they're not forgotten. They can alert them as to what the treatment is likely to be and how soon the patient may be moved to an inpatient bed, Cesta says.
CMs can help morale in ED
Case managers can have a big impact on the morale of the ED staff by freeing them up to do the jobs they were trained for, instead of dealing with paperwork and discharges, Evans-Bailey points out.
"With the nursing shortage, there's a lot more demand on emergency department nurses, and if there's not a case manager present, they have to take on that work," she says.
At one client hospital, Evans-Bailey conducted a pilot study in which a case manager worked in the ED for two weekends.
"The ED staff said they had no idea of the value of case managers and what they did. She helped resolve problems. She knew how to talk to the doctors and how to get the paperwork filled out," Evans-Bailey says.
The ED staff estimated that by having a case manager handle some of the tasks, they saved at least 30 minutes per patient for an admission.
(For more information, contact Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center, e-mail: [email protected]; Joyce Evans-Bailey, RN, MBA, consultant with Compirion Healthcare Solutions, e-mail: [email protected]; Joanna Malcolm, RN, CCM, BSN senior consultant for Pershing, Yoakley & Associates, e-mail: [email protected].)
In today's health care environment, hospitals are challenged on all fronts. The Recovery Audit Contractors (RACs) are carefully scrutinizing hospital records, looking for inappropriate admissions, incorrect level of care, and inaccurate coding in the charts of Medicare patients.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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