Discharge Planning Advisor
Can CM impact this case? That's question in busy ED
ID those with potential to be moved
"Why is the patient here? Why is the patient being admitted? What needs to be done, and is there a possibility it can be done in a less acute setting?"
In his role as case manager in the emergency department (ED) at Massachusetts General Hospital, which sees between 200 and 250 patients a day, says Peter Moran, RNC, BSN, MS, CCM, his focus is always on those questions.
"If you can move them," he adds, "what are the barriers to getting them out? Some clearly can go home, some clearly need to be admitted, but the struggle is to identify cases where case management can have an impact."
One of the things with the biggest payoff in terms of answering those questions in a timely and effective manner, Moran says, is to quickly identify patients who have the potential to be moved.
One target, he notes, might be those who are on Medicare and who have had a three-day stay in the hospital within the past 30 days.
Patients who meet those criteria and who are found not to have an acute medical condition can be moved directly from the ED to a skilled nursing facility (SNF), Moran says. "The key is having the correct information."
Another trigger might be certain diagnoses, he points out, noting that a lot of chest pain cases, for example, can be put on observation status, depending on whether the patient has a history of heart problems — and a lot of payers want them in that designation. If the correct designation occurs upfront in the ED, Moran says, claims can be processed and paid more quickly, with fewer denials.
One problem with finding the cases in which one can have a measurable impact, Moran continues, is that it's difficult to identify these patients without picking up every chart and scanning it - something that's difficult to do in a busy ED.
Mass General is implementing a faster way to identify these patients, he notes, through a report run off the information system it uses for utilization review, which also has a case management component.
He suggests that case managers develop a list of the types of patients they want to target and determine if reports can be generated based on certain diagnoses, repeat visits, or "whatever the [case management] program is aiming to impact."
"Try to use the systems you have," Moran says, "but sometimes the information you want is not found in a standard report. A lot of us have systems that are not state of the art, so you need to create special reports."
Although Mass General is still fine-tuning its report, it has been helpful, he adds. "When I come in, it's not unusual for me to have 15 or 20 people waiting for admission. If I see someone had a Medicare admission and discharge within the past 30 days, I look at those charts first."
On the other hand, if someone comes in and is definitely going to be admitted, that case is not a priority, Moran says. "With certain payers, you can't move a patient [to another level of care] without preapproval, and that will impact how I prioritize certain cases."
"For example, I know for a fact that with Massachusetts Medicaid, I need pre-approval to send someone to a SNF or rehab facility," he says, "so if a patient comes in over the weekend, and if he can't go home, that's a patient I cannot impact - he will be admitted. I can do an initial assessment, I can identify where the patient would like to go and I can have the patient screened, but I know I can't get approval until Monday."
Complicating the process, Moran notes, is the fact that most EDs are "getting overwhelmed with geriatric and mental health [cases]. The patients are getting older, and a lot of them are alone."
"We're also starting to see more people who are primary caretakers who need to be admitted to the hospital," he adds. "When they get hospitalized, what happens to the person they are caring for? If the 92-year-old [patient] has been taking care of a mentally impaired person, who is now 64, is there a way we can arrange for someone to take care of the dependent? Can we mobilize family members or community agencies?"
If not, Moran notes, such patients will frequently present to the ED and may become "social admissions" — patients who have no acute medical needs but who are not safe to discharge.
During the hours of 9 a.m. to 7 p.m., when case management services are available, there is time to see only so many patients, he says. "I'm being used for the person who is in the ED because he or she had a fall, is frail, elderly, and lives alone, and for the homeless and uninsured populations."
In addition, Moran says, he is consulted by physicians and families looking for assistance in caring for chronically ill people at home.
In looking at whether the person is fit to go home, he points out, he must consider what the person's "baseline" is: "How are they managing, what services are in place? So many are chronic — they're at home on a banana peel anyway — the question is, "Is [the current condition] different, or is this their baseline?"
[For more information, contact Peter Moran at [email protected].]
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