Case Management Challenges in the Emergency Department
September 1, 2023 6 minutes read
By Jeni Miller
Hospital case management already is unique. But carrying out this role in the ED brings even more challenge and intensity to bear. It also affects operations and well-being in the rest of the hospital.
“The emergency department is one of the primary points of entry for the hospital,” says Bonnie Geld, MSW, president and CEO of The Center for Case Management. “It’s the biggest opportunity to make sure you get everything right — from determining the appropriate status of a patient coming into the hospital to avoiding unnecessary hospitalization.”
The ED stay is remarkably different from that of other units since the visit is intended to be brief yet highly efficient. “[In other units], the stay is maybe a couple days, but in the ED, you have to identify the needs of the patient, plan out what should happen next, and put that plan into place in a very short span of time, ideally less than five hours,” Geld says.
The key is patient identification, Geld notes. The Center for Case Management uses a proprietary tactic to help case managers improve speed and efficiency — both of which are crucial in the ED.
“Can the case manager get in to identify the patient as early in the stay as possible? That’s vital,” Geld says. “We built a model that makes patient identification immediately possible. It’s a strategy we use to help case managers figure it out more quickly.”
Heidi Rohloff, RN, BSN, MSN, ACNP, a consultant for The Center for Case Management, says taking care to identify what is happening with each patient is essential for proper surveilling of the entire hospital.
“Surveillance is essential, and it allows us to see what gaps in care there may be in that environment,” Rohloff shares. “Case management is, first of all, mindful of the level of care needed for the patient coming in the door. They’re concerned about how sick the patient is and what would be the most appropriate clinical bed for their needs in the hospital. Then, mirror and review that against insurance.”
One major goal of case managers is to support the ED to ensure excellent patient flow, Geld notes.
While encouraging that patient flow is a priority, it is not always possible due to inpatient bed shortages. It is crucial, especially in those situations, to ensure patients are not “orphaned” while waiting for an inpatient bed.
“They need to be assessed to confirm that the level of care is still appropriate,” Rohloff explains. “They may be better or worse and in need of a higher or lower level of care. Sometimes, there may be patients who have stayed in the ER long enough and can go home.”
ED Overutilization
ED case management is not without its underlying problems and challenges, even aside from the intense and fast-paced nature of the department. One issue is the volume of “boarders” in the ED — those who use the hospital for non-emergent issues or who are likely to stay due to homelessness or other needs.
“Boarding is a norm in the ED, and case managers work toward facilitating care for those patients,” Rohloff says. “Case managers are the lens for navigating the ED, especially in identifying why some patients keep coming back. Social determinants of health are a big issue, understanding why they are they utilizing the ED is an issue, and we work in addressing these gaps.”
Researchers have noted how frequent users (FUs) and boarders use ED services, and how case management affects this group of people. A 2019 report in the National Library of Medicine stated that “[a]ccording to a systematic review carried out in the USA, FUs are identified as patients who visit the ED at least four times a year (or three times a month). They represent between 4.5% and 8% of the patients who use the provided service and between 21% and 28% of all the ED medical activity.” The result of case management intervention, according to the report, was “a reduction of ED utilization and … cost reduction.” The researchers found “individual care plan[s] with telephone contact, supportive group therapy, facilitated contacts with healthcare providers, and informatics system for immediate identification” were the tools widely used by case managers to alleviate the issues leading to frequent ED usage and boarding.1
Other issues in the ED reflect a widespread and common problem that hospitals in general are facing: shortages. “Many hospitals assign case managers to the ED, but when staff is out from the inpatient side, then ED case managers are reassigned to inpatient,” Rohloff explains. “But the ED is not an area you should ever have uncovered. This is a challenge for ED programs, and often a patient ends up getting admitted when they shouldn’t.”
“Case managers are vital in the ED because they are looking at all of the financial aspects of patient, as well as clinical aspects — looking at it globally,” Rohloff adds. “They can filter for the organization at that ED entry point. Case managers know that if they don’t get it right at the beginning, it can make the whole stay in the hospital that much more troublesome.”
Geld and Rohloff often see how staffing shortages in hospitals too frequently result in pulling the ED case manager out and reassigning them to another unit — a practice that strains the whole process. Rather, best practice is to ensure highly capable case managers are “embedded in the ER, and not a remote position, to allow for shoulder-to-shoulder discussion,” Rohloff says. “It’s important to lay eyes on the patient. You can look at the chart and not appreciate what the patient and their situation actually look like. If you’re making all clinical predictions and decisions based on the chart alone, that’s not as good a practice.”
Rohloff notes moving case managers away from the ED to cover other areas should be a non-option because it gives up that valuable surveillance needed to keep processes running smoothly and patients flowing to the next level.
“It’s a severe issue if no one is guiding that patient and reviewing that case,” Rohloff adds. “If a patient is out of network, and it’s not caught, it’s a problem. If that patient isn’t assessed and reviewed by the time they are going upstairs [to inpatient], it could be 48 hours later — and that’s 48 hours too late.”
Case Management Life in the ED
Considering the challenges of case management in the ED, Rohloff shares what she believes are important traits for the ED case manager to cultivate. Above all, a good clinical background, flexibility to pivot when needed, and the ability to be present at the patient’s bedside were most significant. Case managers also must be able to handle the quick pace of the ED.
“It can be a chaotic environment, so if a person feels that everything has to be linear, this may not be good fit for them,” Rohloff explains. “In the ED, we call it ‘chronic interruptus.’ If constant interruption is frustrating for a particular person, the ED may not be a good fit.”
Geld also lists several helpful characteristics of a successful ED case manager, including the ability to “speak the language of the ED” and “earn the partnership and confidence of the ED doctors.” Excellent critical thinking skills also are non-negotiable.
Case managers who wish to work in the ED also should consider continuing education, since the work requires someone who is data-driven and understands the financial aspects of the position. “They need to understand the disease and clinical trajectory of the patient, even as they prioritize and reprioritize,” Rohloff says. “It can be very challenging.”
Good case management leadership also can be an asset in a fast-paced, highly energized, and emotionally exhausting role. “The leadership should help case managers manage the boundaries of their role, because if they have a lack of understanding of that, it can be awful,” Geld notes.
Case Managers Are Invaluable
The potential for ED case managers to help set the tone and control the flow of patients throughout the hospital is incredible. Seeing this important role as an opportunity can determine whether the hospital experiences high success in not only appropriate patient care, but also the bottom line.
“Case managers in the ED can improve patient flow to inpatient [units], decrease readmissions, and there are great opportunities for improving organizational metrics and managing capacity,” Geld says. “We just need to get out there every day and demonstrate that it’s an outcomes-driven role.”
Rohloff recalls how her clients have reacted when they see the result of strong case management in the ED. “When they see improvement that helps their areas, they get excited about that,” she explains. “To show how case managers kept the organization from admitting patients who didn’t need to be admitted, and to make other discharge plans for those patients and ‘create’ more beds for the hospital — that’s music to their ears.”
REFERENCE
- Di Mauro R, Di Silvio V, Bosco P, et al. Case management programs in emergency department to reduce frequent user visits: A systematic review. Acta Biomed 2019;90:34-40.
Hospital case management already is unique. But carrying out this role in the ED brings even more challenge and intensity to bear. It also affects operations and well-being in the rest of the hospital.
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