Managed care pressures heighten ED risks
Learn how to handle 'social admissions'
In the "old days," patients didn't hesitate to drop into their local emergency department (ED) if they had no idea of where else to go. Managed care, however, has little patience for costly, unnecessary ED care.
To resolve this, many hospitals are using case managers and social workers to help direct the sometimes convoluted maze of patient admission and discharge. That's a viable option, but it must be used with care to avoid legal risk, experts warn.
The use of case managers and social workers in emergency room discharge planning is popular with patients, says Kathy Finch, BSN, nurse manager of the emergency department at Duke University Medical Center in Durham, NC. "There is so much happening in the health care industry that folks are not aware of and do not know how to access the system," she points out. And the confusion isn't limited to the "lay public."
"We have sophisticated physicians here who do not know how to access the whole system, so I would imagine that a patient would have a more difficult time trying to do so," says Finch. "A case manager can help a patient by telling them who they need to call to set up home care visits, whether the home health care aide is credentialed [by an organization], and whether their insurance will pay for the services."
Both case managers and social workers can be effective discharge management tools for the emergency room. But, due to the wide range of medical and social issues that arise in emergency departments, hospitals should proceed with caution when using them, risk management experts warn.
"Hospitals have to determine who is the most appropriate and competent person to fulfill the needs of discharge planning," says Fay Rozovsky, JD, MPH, DASHRM, director of risk management and legal affairs, AIG Consultants in Wynnewood, PA. "Whoever does it has to remember that their duty is to the patient."
The need for discharge planning in the emergency department most frequently arises with so-called "social admissions," such as elderly patients and abused women and children. In the past, hospitals frequently admitted these people and addressed their social and related medical needs. Now insurance companies will not approve these admissions, but hospitals still are legally and -- some feel morally -- obligated to help these patients.
For example, when elderly patients would present themselves to the emergency room at Community Medical Center in Toms River, NJ, after falling but not injuring themselves, the hospital frequently would admit them to allow them to recuperate and to address any services or equipment that they might need when they went home, says risk manager Delores Merceron. While these types of patients now are sent directly home, they still may need equipment, care, or services which Community Medical Center planned to address through the use of case managers.
In the example of the elderly fall victim, Community Medical Center's plan was, after any necessary medical treatment, to provide the fall victim with a walker to use at home as a courtesy. The emergency room case manager would instruct the patient on its usage and send him or her home.
But such courtesies could expose the hospital to liability, Merceron notes. If the patient falls because he was not properly instructed or if a case manager recommends a home health aide who is abusive to the patient, the hospital would be likely to be sued.
While liability will always exist, risk management experts say that it can be minimized through a careful division of labor when using case managers and social workers in the emergency department for these purposes. Who would you call?
"Whoever is fulfilling that job description must have the requisite skill set and demonstrated ability to deal with the problem," Rozovsky says. "They also need to be aware of the complexities involved. For example, if you have a diabetic patient presenting to the emergency room with an orthopedic problem, it certainly would be helpful for the case manager to be able to call in all the necessary resources."
"Being able to have the wiggle room to draw on other resources is very important," she says.
For that reason, Duke University Medical Center in Durham, NC, has been dividing the management of patients discharged from its emergency department between social workers and case managers or resource nurses, says Finch.
Depending on the patients' needs, the emergency room doctors and nurses at Duke Medical Center will call one of these discharge management professionals to assist the patients before they are discharged. For clinical needs such as arranging home IV therapy or outpatient referrals, Duke uses case managers because they are required to be nurses with at least a bachelor's degree in nursing, Finch says.
Social workers are used at Duke to assist emergency department patients with issues relating to outside facilities such as finding housing, shelters, clothing or arranging transportation, Finch says.
Duke Medical Center requires its social workers to have master's degrees to ensure a level of training and knowledge of resources to help its patients. Patients with psychiatric needs often fall into a gray area and require special attention. "Traditionally, social workers handled them," Finch says. "But there are so many patients that have true physical needs, that somebody needs to get into their house to bathe them or teach them how to use medical devices."
Don't confuse the MCO case managers
Many managed care organizations employ their own case managers, but they serve a different function and must not be confused with a hospital's case manager.
"A hospital may get a call from a MCO saying our discharge planner will take over the patient's care," Rozovsky says. "It is not the MCO's role to usurp the hospital's role. You can do it in concert with them and should do so, so there is a smooth transition."
In addition to deciding whether and how to use case managers in the emergency department, risk managers tell HRM that they also are questioning whether they should have a dedicated case manager and/or social worker for the emergency department.
Due to the wide range of issues emergency departments confront each day, risk management experts recommend against having a dedicated case manager or social worker in the emergency department. That person could not be trained well enough in every scope of practice or social work discipline to withstand a claim of negligence in the event a hospital were sued. Instead, risk management experts suggest arranging a system in which case managers from each hospital department can be accessed.
At Duke University Medical Center, emergency department nurses and doctors call case managers from the specific department to help manage the patient's care along a continuum for each specialty. "It may be impossible for one case manager to know the entire scope of practice for every emergency need," Finch notes.
If your facility is planning to use case managers and social workers in its emergency department, make sure that these professionals are always accessible.
"They have to be available 24 hours a day, seven days a week because the problems that require their assistance typically arise at seven in the morning," says Finch.
No matter how well trained and how well organized your emergency department case managers are, a hospital still can be exposed to a claim if patients claim they were not adequately instructed on the use of equipment or were referred to a substandard outpatient facility. This issue underscores the importance of documenting the interactions between case managers or social workers and patients.
"The key to limiting your exposure is good documentation," says Finch. "The physician must clearly make the judgment that the patient can go home under certain circumstances, and the [case manager] must carefully document the patient's understanding."
Because discharge instructions and physicians' orders take on heightened importance when case managers enter the picture, risk managers may want to consider having their information management department purchase computer software which allows the discharge instructions to be printed. These systems often can be programmed to follow certain practice guidelines and will print the instructions in several different languages depending on the patient's native tongue.
Having the patient sign a copy of the printed instructions, which should be kept in the patient's chart, will help minimize a hospital's exposure.
Regardless of whether the patient's health care insurance will pay for hospitalization, risk managers need to ensure that case managers and social workers are not a substitute for proper medical care, Rozovsky cautions. Otherwise, the hospital could find itself under scrutiny under the federal Emergency Medical Treatment and Active Labor Act (EMTALA).
On the other hand, if used in concert with good medical care, case managers and social workers can truly improve patient care.
"It's encouraging because the patient then has access to a true continuum of care," says Rozovsky. "That really is managed care from the clinical side: managing resources to meet the patient's clinical needs. If that happens, then risk exposure goes right down." *
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