ED Navigators prevent unnecessary admissions
RNs help connect patients to community resources
By identifying community resources for homeless and near-homeless patients, Montefiore Medical Center in the Bronx, NY, is cutting down preventable admissions.
Nurse case managers act as patient navigators in the emergency department and work closely with emergency department social workers to prevent unnecessary admissions. Social workers cover the emergency department 24 hours a day, seven days a week. The emergency department navigators work from 9 a.m. to 7 p.m.
The hospital met its goal of 3,000 fewer admissions in 2011 than in 2010, according to Anne Meara, RN, MBA, assistant vice president for network care management for the 1,491-bed medical center. "It's hard to separate the outcomes for the navigator program from other initiatives but it is one of the things that have contributed to our reduction in readmissions," Meara says.
The navigators work with patients who utilize the emergency department for a variety of reasons. Some have significant medical conditions in addition to complex psychosocial issues. Others have behavioral and substance abuse issues in addition to the medical problems.
The hospital is located in one of the poorest counties in the country, and 80% of patients are covered by Medicare or Medicaid. "Many patients are pre-homeless, and the attending physicians may plan to admit them because they do not feel comfortable sending them out without a definite place to go," Meara says.
When patients who are at high risk for a preventable admission come into the hospital, the registration system alerts the emergency department navigator and social worker. Patients who meet criteria for an intervention include patients who were discharged from the hospital in the past 30 days, or have had five emergency department visits in the last year, those who are homeless, living in a shelter, or who have tenuous housing situations.
The navigators often meet with the patient before he or she is evaluated by the physician. They work with the physician to determine an alternative to hospitalization by arranging services in the community, Meara says. "We emphasize to the emergency department staff that we are not telling them not to admit patients if they need it, but that we are working with them to provide resources to prevent unnecessary admissions," she says.
For instance, when a woman brought in her mother after a fall, the emergency department navigator intervened and was able to get her admitted to a skilled nursing facility, rather than being admitted to the hospital which was the original plan.
In the past, some patients were admitted for brief periods of time because they had psychosocial problems that were too complex for the staff to handle in a short time. The program helps get them connected to the right services in the community.
"By introducing this program into the emergency department, we have educated the emergency department staff to address more than just the medical complaints, and to look at other factors that are responsible for patients making multiple visits to the emergency department, and work with the navigators to find alternatives to admissions," she says.
Most of the patients who are referred to the program have housing issues. The case manager navigators work closely with a community-based housing assistance organization that has a variety of levels of care and programs including shelters for individuals, and family shelters. When the physician is considering admitting patients because they don't have a place to go, the navigator contacts the organization which sends a van to transport the patients to a residential facility and works with the navigator to arrange follow-up medical care.
The navigators have monthly meetings with the housing assistance organization, and reviews the cases both are working on. "They utilize our healthcare system and help us with finding placement for our patients," Meara says.
If someone is in a shelter, it's difficult to coordinate their care, Meara points out. For instance, one patient gets primary care in an ambulatory setting but also comes to the emergency department frequently. The navigator team is working with the staff at the shelter to ensure that the patient gets the care he needs in an appropriate setting. Another patient comes to the emergency department to get insulin because he doesn't have access to proper storage facilities in the shelter. "We're working with the shelter to come up with a solution," she says.
The nurse navigators are also partnering with the local skilled nursing facilities so if they send patients to the emergency department for issues such as chest pain, the patients can return to the facility after workup and treatment, rather than being admitted to the hospital.
"Over time, the program is evolving to address a number of issues that in the past, typically resulted in an admission. Now, because the emergency department staff understands the role of the navigators, we can avert those admissions," Meara says.
Some admissions are not preventative because patients have complex medical conditions that require a hospital stay, Meara says. "But by having case managers in the emergency department collaborating with the clinicians and providing feedback to the people who take care of the person in the shelter, we can establish continuity in care across settings and into the community. This program has played a significant role in changing the mindset of the emergency department team. It's given them the confidence and comfort level to discharge people back to the community when resources are in place," she says.
Source
For more information contact:
- Anne Meara, RN, MBA, Assistant Vice President for Network Care Management, Montefiore Medical Center, Bronx, NY. E-mail: [email protected].
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