Dear Director: My hospital has offered to put a case manager in the ED but asked me to create the job description. Can you give me a hand?
Adding a case manager to the ED team can have a tremendously positive impact on ED patients and the hospital. Just like when we add physician staff, however, the hospital will be looking for the return on their investment, so it will be helpful to work carefully with your care management team to better understand the overall hospital goals and how their ROI will be realized.
Your hospital most likely has a care management department with case managers dispersed throughout many units of your hospital. Depending on the goals of the unit, case managers are typically a nurse or a licensed clinical social worker (LCSW). Although they have skill sets that overlap (or can be balanced out by training and education), there are a few differences in what each brings to the table. The decision about whether to use a nurse or a clinical social worker as a case manager will be based on the job description, goals of the department, and even the department’s acuity.
Many EDs use their case manager to help determine whether a patient should be hospitalized as a full admission or as observation status. ere can be a lot of money involved for the hospital in getting this decision right, so this tends to be the easiest argument to prove the ROI. RNs have the edge here. Additionally, a nurse will likely have an easier time helping patients arrange appropriate home health care services (which could prevent an admission). On the other hand, a LCSW can help provide assessments and assist with placement of the ED’s psychiatric patients. LCSWs are commonly used in high risk and high stress areas such as the ICU, the NICU, and the L&D department because they can also address the traumatic, psychosocial needs of patients and their family members during a crisis (family of a cardiac arrest, a SIDs death). I used to work in an ED where (at least it felt like) we had five cardiac arrests a day. The LCSWs I worked with there made my job much easier, as they spent time helping families on the path to recovery. Both nurses and LCSWs can effectively do discharge planning and partner with outside agencies to provide outpatient services.
Dave Kindig and Greg Stoddart, in 2003, proposed the definition of population health as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” Hospitals are now getting into the business of population health, so a case manager can help reduce ED visits of some patients with chronic diseases by arranging appropriate outpatient care (imagine patients with chronic ascites not coming to the ED when they need a paracentesis but rather are appropriately scheduled for an outpatient procedure), and by providing resources to patients so they can be managed outside of the hospital setting. Care managers may be able to play a bigger role as hospitals try to reduce 30-day readmissions. As more patients enter into bundled care payment programs, look for case managers to be more involved in routine patient care.
Many hospitals have an ED care plan committee to help address patients considered “high utilizers.” These patients often have a negative financial impact on hospitals and disproportionately occupy staff resources. The case manager should be a critical component of this committee, helping to “enforce” the plans. The case manager can meet with high-utilizing patients in the ED, help the patients make appointments or fill prescriptions, contact a specialist (picture a chronic headache patient whose neurologist needs to be informed), and even help to update the patient’s care plan when appropriate.
Of all the decisions that emergency physicians make, the most costly decision is the one to admit the patient. For hospitals or primary care groups that participate in an Accountable Care Organization (ACO), there’s a lot of motivation to reduce the overall cost of care. Because of this, many EDs use case managers to help get the “observation vs. admission” decision right. The billing aspects of these cases are complicated but translate into significant financial penalties if the decision isn’t correct up front. For many patients who end up in “observation status” but who start off as “admissions,” the hospital loses the hours of care provided while the patient was not in that “observation” status. A case manager can also help justify admissions. I learned this first hand when I had a case manager tell me that a patient with an alcohol level >400 met admission criteria. While that criteria has been stricken from the records now, it was a huge help getting a potentially difficult patient out of my ED 12 hours earlier than usual by telling my hospitalists that “case management told me the patient met admission criteria.”
Case managers can also prevent admissions by providing patients with the resources they need to manage their condition as outpatients. It could be as simple as ensuring that DVT patients can obtain medication from the pharmacy (avoiding an observation stay while treatment is arranged). I’ve seen case managers prevent unnecessary hospitalizations in a variety of settings, including getting patients directly into a hospice bed or an assisted living facility from the ED. More commonly, it’s arranging for home physical or occupational therapy, home nursing, a nurse aide to assist the patient with activities of daily living, or even providing a hospital bed for home. An emergency physician doesn’t have the time or expertise to arrange many of these scenarios, so it is often easier for us to hit the “easy button” admit patients for a care management team assessment. When the hospital provides the case manager to the ED, we’re bringing the expertise directly to the patient.
One ED director I spoke with told me of his department’s geriatric case manager. During her scheduled hours, she makes an effort to see every patient over the age of 65 to answer any questions and troubleshoot problems with home care. Over the last few years, I’ve had to review several complaints that involved dissatisfied elderly patients who were discharged and had trouble caring for themselves afterwards. In each case, I thought the decision to discharge was appropriate, but I also think that geriatric patients may often bene t from some assistance at home. A case manager could certainly help provide that assessment and assist in making appropriate recommendations.
The Nuts and Bolts
For case managers to be most effective, they need to be a part of the ED team. This starts with an analysis of which hours they could be most impactful — most likely during the 11a-11p timeframe — which is a departure from the typical 7a-5p hours that may define the hospital’s care management department. Being situated in the ED, the case manager needs to be able to frequently communicate with the docs and nurses so that they have a general awareness of what’s going on in the ED. While communication could occur through the tracking board or telephone, the most success I’ve had with a case manager was someone who was actively going through the patient list and by reviewing the physician notes, had a pretty good sense of what direction most patients were headed and what interventions would have the most impact. I love going to patient’s clip board to begin my decision making (home vs. obs vs. admit) and getting surprised to see a report from our case manager listing out the admission criteria that were met or suggesting that the patient may be a candidate for home nursing care. Sure makes my job easier and, if needed, my conversation with the hospitalist easier.
Adding a case manager to the ED can have tremendous benefit. Depending on the job description and goals of the department, a case manager can improve outpatient home care, impact the high utilizer patient population, assist with psychiatric patient care, and serve as a resource for admission decisions.