News March 6, 2007

Case Managers Improve ED Care

Emergency departments in hospitals across the country are finding that adding an RN case manager or discharge planner to the team improves patient flow and decreases inappropriate admissions.

“Holding borders or inpatients, emergency departments are faced with complex and difficult case management issues we have never been faced with in the past,” said Donna L. Mason, RN, MS, CEN, president-elect of the Emergency Nurses Association and manager of the adult emergency department at Vanderbilt University Medical Center, Nashville, Tennessee. “More and more emergency departments are putting case managers on.”

EDs may call on case managers to talk with newly diagnosed patients with HIV or cancer, to answer their questions and get them the community resources they need. They also help uninsured and frequent patients connect with primary-care providers for a successful transition to a medical home.

“We try to close the loop for the patients, to make sure all of the bases are covered as far as their care,” said Wendy Rash, RN, BSN, CEN, case manager in the emergency department at Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina. “A lot of the time, I get comments from patients thanking me for calling and helping.”

Rash can check if patients have scheduled appointments at the health system’s clinics. If she does not find a set date 72 hours to 96 hours after discharge, she notifies the hospital’s call center to contact patients, inquire about the reason and offer to set an appointment.

ED case managers at Wake Forest focus on patients’ medical needs and collaborate with social workers, also assigned to the ED, on psychosocial issues, including domestic violence, child abuse, or elder abuse and neglect. They often can intercede and arrange home services when a physician wants to admit a patient who does not truly require inpatient care.

“We have to be the people who ask the question why,” said Pat Mabe, RN, MSN, CCM, ACM, manager of the department of case management and social work at Wake Forest, which treats more than 60,000 patients a year in the ED. We ask “what is the benefit for the patient, for the hospital and why not do it somewhere else.”

Sharon Simmons, CRNP, MSN, CNOR, system director of quality and case management at Baptist Health System Inc. in Alabama, finds physicians are often not aware of all of the home health services available, such as administering IV antibiotics in the home, but RN case managers do and can prevent an inappropriate admission for which insurers will often deny coverage.

“It’s making sure the patient gets the care needed at the appropriate level of care,” said Simmons.

Employing case managers in the ED has improved Baptist Health’s and Wake Forest’s patient satisfaction and throughput.

Tampa General Hospital, in Florida, has experienced similar benefits with its RN discharge-planning program. The planners meet with every patient on the way out, freeing up a bed as patient teaching continues.

“Because of the busyness of the ER, patients often feel their needs are not listened to, so they appreciate the fact somebody has asked them at the end if there is something they can help with,” said Glenda Wright, RN, MHA, outcomes manager for the emergency room at Tampa General. “This gives them an opportunity to ask questions.”

Case managers also, typically, follow up with patients and their physicians if an abnormal radiology or laboratory finding comes back after discharge, such as a urine culture showing resistance to the drug the patient received.

“We’re going one step beyond what we’re typically used to doing in the emergency department,” Mason said. “The staff nurses love it, because it takes the workload off of them.”

Vanderbilt’s case managers have extensive emergency department experience, so co-workers respect them. They accept and appreciate the case managers researching and developing standards of care and protocols.

At Baptist Health the case managers also monitor whether the hospital follows benchmark standards of appropriate care. They also try to capture all of the patients’ co-morbidities to ensure the paperwork is coded for the correct reimbursement.

Case managers also usually follow up on the patients who left without being seen. Although with the improved flow, wait times decrease and fewer patients take off.

“I contact them to see if they are doing OK and see if I can help them get into their primary-care physician or offer them to come back to the emergency department,” Rash said.

At Tampa General, the RN discharge planners also call all of the chest-pain patients released after a negative workup at 24 hours and 30 days to make sure they have not developed any problems.

Baptist Health case mangers call “frequent fliers” to check on the patients’ medication compliance and status, hoping to catch any problems early with a trip to the primary-care provider rather than the ED.

Case managers enjoy the challenge of figuring out what will work best for patients and of having the time for teaching. It’s a different type of ED nursing, but every bit as demanding of their skills.

“Being a patient advocate and being one step away from the bedside and looking at the patient as a whole really can be very rewarding,” Mabe said. “It also can make a huge difference in a patient’s life.”