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Emergency Department Case Management EMERGENCY DEPARTMENT CASE MANAGEMENT By Linda Sallee, Haley Rhodes, Sapna Patel, Cathleen Trespasz Healthcare consumers are becoming Benefits of an ED case management program: more empowered to have healthcare • Improved patient experience on their terms. With telemedicine, mobile apps and outpatient centers, • Improved patient throughput patients can receive high-quality • Increased adherence to new care that is convenient and low cost. regulatory requirements While emergency departments (ED) • Increased capacity (backfill) provide high-quality care, the long wait times and high cost of care • Reduced denials, inpatient (IP) length of stay (LOS) and 30-day readmissions often leave patients frustrated. At the same time, as value-based payment • Prevented inappropriate admissions models replace fee-for-service • Reduced ED length of stay (LOS) models, hospitals must do more • Managed observation patients (OBS) and high- to manage care in the appropriate use patients more efficiently setting in order to drive down costs. • Increased correct status (inpatient, outpatient and observation) determination upon admission ED case management programs are a win-win ED Case Management Team Role Delineation for patients and ED CASE SOCIAL WORKER healthcare organizations. MANAGER • Psychosocial • Initial medical interventions necessity review ED • Complex transition Considering that appropriately 70 percent • Clinical care planning from the ED coordination of hospital admissions enter through the ED, • Transition planning addressing the needs of these patients and from the ED lowering the cost of care in this arena can have a • Identifying significant impact across an organization. ED case psychosocial needs management programs can do just that. for consult to the social worker Inpatient=IP, Outpatient=OP, Observation=OBS EMERGENCY DEPARTMENT CASE MANAGEMENT HURON | 2 The Role of the Transition Planning ED Case Manager ED case managers should collaborate with ED social workers to create patients’ discharge plans. The ED case manager is responsible for an initial There are many effective models for discharge medical necessity review for admitted patients and planning. Best practices include: transition planning. Since ED volumes fluctuate significantly, staffing of case managers must • A social worker performs transition planning for account for the time it takes to complete various patients with complex psychosocial needs. tasks at a given point in time rather than staffing on a patient-beds ratio. It is also important to • A house case manager and/or social worker assess if a case manager is needed around the performs discharge planning after admission for clock or if 12 or 18 hours of coverage is adequate. patients who are admitted from the ED. • An ED case manager performs simple transition Initial Medical planning, when necessary. Necessity Review Following these best practices ensures that all employees are practicing at the top of their license. As hospitals increase their focus on revenue and patient flow in an effort to improve utilization, Transition planning from a team of ED case initial medical necessity reviews are critical managers and ED social workers can involve as they help determine the appropriate initial assistance with setting up equipment and placement for patients. During these reviews, medication, home health referral and post-acute the ED case manager should use an approved facility transfers. The team should collaborate tool (e.g., InterQual, MCG) to help assess the with the ED provider to understand the expected appropriate admission status (inpatient or needs of the patient and provide recommendations observation). This reduces future changes to for safe transition plans to prevent inappropriate status level of care needed post-ED discharge inpatient admissions. While many physicians do (e.g., acute, intermediate, critical). not feel confident in addressing the social needs of patients and may not have the capacity to do so in Delays in status determination often occur when the fast-paced ED environment, collaboration with critical documentation, including diagnostic test this team can fill that gap and provide patients with results, are unavailable at ED admittance. To a strong network of resources to reduce risks of avoid these delays the ED case manager should repeat ED visits. Approximately 40-50 percent of speak to an ED provider to understand their readmissions are caused by lack of resources and clinical impression of the case. This will provide social problems. As a result, it is critical to discharge them with the information needed to discuss patients from the ED with appropriate resources the expected treatment period, and appropriate and services that mitigate the risk of readmission. admission status and level of care with the admitting provider in order to complete the initial medical necessity review. When a lack of consensus regarding the appropriate admission status and/or level of care occurs the case manager should contact the designated physician advisor who provides insight on the case. Inpatient=IP, Outpatient=OP, Observation=OBS EMERGENCY DEPARTMENT CASE MANAGEMENT HURON | 3 Manage Regulatory issues that impact ED processes: High-Use Patients • CMS Two Midnight Rule Under value-based payment models, providing the — Admission begins when physician order appropriate type of care in the appropriate setting is written becomes increasingly important. Many patients — Documentation should include who are high users of ED services do not need this expectation of two midnights and high level of care and as a result hospitals must try justification (medical necessity) to redirect these patients to other care settings. ED case management programs can put a plan in — Status (IP, OP, OBS) must be ordered place that will do just that. • CMS Condition Code 44 The first step that must be taken is to establish — Issued when a patient is placed in IP criteria that defines a high user. Then, when a status and subsequently changed to patient who meets high user criteria is admitted, OBS based upon medical necessity they would automatically be flagged in the EHR. • Medicare Outpatient Observation Notice (MOON) The ED case manager and social worker should manage high-user patients together, — Notification to patient that they are in as psychosocial causes often contribute to an outpatient observation status frequent ED visits. By working together to • Emergency Medical Treatment and Active Labor create a comprehensive post-discharge care Act (EMTALA) plan that includes primary care coordination, insurance enrollment, transportation and housing — Medical screening required regardless of arrangements, they can address the patient’s their ability to pay or insurance status that medical and psychosocial needs. If the patient is required before disposition from the ED returns, this care plan should be reassessed to ensure the patient is receiving the appropriate coordinated services, beyond medical care, to ED Case reduce their ED use. Management Metrics Metrics are essential to monitor the impact of the ED case manager role. It is a best practice role to Address implement a robust set of metrics. A sample list of Regulatory Changes metrics include: Hospitals are facing increased pressure from the Centers for Medicare and Medicaid Services PHYSICIAN ADVISOR METRICS (CMS), state and commercial payers to provide the highest quality and most cost-effective Internal physician advisor referrals (Count / %) care to patients. The Medicare Conditions of Physician advisor referrals average response time (hours) Participation (CoP) outlines the responsibility Physician advisor referrals completed (%) of the hospital in assuring medical necessity External secondary review referrals (Count / %) for admission and appropriate level of care and LOS. The CMS CoP applies only to Medicare and DATA NEEDED FOR ANALYSIS Medicaid beneficiaries, but Medicare Advantage Admission volume and commercial providers often attempt to invoke Discharge volume these regulations. Inpatient=IP, Outpatient=OP, Observation=OBS EMERGENCY DEPARTMENT CASE MANAGEMENT HURON | 4 • Notify admitting physician of recommended STATUS METRICS status in the electronic health record (EHR) OBS LOS (Hours) OBS Rate (%) OBS LOS Distribution (%) ED Case OBS to IP status changes (Count / %) Management Success IP to OBS changes (Condition Code 44s) (Count / %) By improving the patient experience and providing Patient status changes (Count) the appropriate level of care to each patient, patients and hospitals will benefit. Successful case INITIAL MEDICAL NECESSITY REVIEW METRICS management programs will: Initial medical necessity review completed in the ED • Better manage frequent ED users. (Count / %) Initial medical necessity review not met in the ED (Count) EXPAND PATIENT/FAMILY KNOWLEDGE AND UNDERSTANDING OF INSURANCE COVERAGE. Initial medical necessity reviews completed at point of entry (%) • Improve correct status determination upon admission leading to reduced re-work for Case management admission assessment complete (Count / %) inpatient case managers and a decline in missed IP to OBS changes (Condition Code 44s) (Count / %) revenue from cases where the correct status is Patient status changes (Count) not determined in time. • Improve patient placement to the correct unit, TRANSITION PLANNING reducing unnecessary transfers and interruptions Progression of care referrals to patient care. Referral to discharge time • Reduce denials related to medical necessity
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