Whitepaper | Change Healthcare
Hospital emergency departments (ED) sit at the crux of one of the most expensive decisions in the healthcare system: whether to admit a patient, and to which level of care. Enter the ED case manager. They play a key role in helping clinicians make appropriate admission decisions, while simultaneously ensuring patients are receiving the most appropriate care, and helping to forge connections with resources and services outside of the hospital setting. Unfortunately, many hospitals don’t fully staff their EDs with case managers, and they should.
ED Case Managers Impact Care Quality
Hospitals and health systems that see the value of an effective case management program in the ED, can point to fewer unnecessary admissions, shorter ED wait times, shorter length of stay, and improved discharge and transition planning. That’s because ED case managers are on the front line, helping clinicians to determine appropriate level of care at the outset, managing care transitions and building relationships with community resources. In this front-line role, case managers can help to establish if a patient meets the criteria for admission and ensure that there is good documentation to support the decision. For patients who don’t meet medical necessity, the case manager is in the perfect position to arrange for alternative care using appropriate resources.1
The ED case managers work collaboratively with all hospital departments to facilitate patient flow and coordination of other services beyond hospitalization, such as home care, skilled nursing facilities or other outpatient services.2 “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’ and admit patients,” says Dr. Silverman, Chairman of Emergency Medicine at the Virginia Hospital Center. “When the hospital provides the case manager to the ED, we’re bringing the expertise directly to the patient.”3
ED case managers can also help ensure patients are receiving the right intensity of care. One study found many patients admitted to the intensive care unit (ICU) may be unlikely to benefit from invasive and potentially harmful ICU treatments.4 An effective ED case management program can help identify which patients have conditions that could potentially be managed in non-ICU settings.
How to add a case manager to the ED
Get a sponsor • Run a pilot • Measure everything
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Case managers embedded in the ED also regularly uncover non-medical issues, such as homelessness, social isolation and unemployment.5 Rather than have patients with socially complex needs transition into acute care, the case manager will address their behavioral or social concerns. Arranging a safe place to sleep and food to eat can aid recovery and help patients stay out of the hospital.
ED Case Managers Impact The Bottom Line
The right care for patients is also the right approach for the hospital, promoting quality and cost-effective outcomes. ED case management activities, such as utilization management, care coordination, and discharge planning are closely aligned to the revenue cycle. The impact on financial outcomes is demonstrated by a case study from Lee Memorial Health System in Fort Myers, FL. There, the case management department saved $4.5 million as a result of having case managers in the emergency department who ensured that patients were in the right status — inpatient versus outpatient with observation services — and avoided unnecessary inpatient admissions by transferring patients to a more appropriate level of care.6
Given the financial risk facing hospitals, it’s crucial to get the admission status right for each patient. Inpatient care that could be delivered on an outpatient basis is most likely to be denied by payers, and the hospital won’t receive any reimbursement for the care provided. With ED case managers helping to correctly identify patients who are appropriate for observation, the hospital can capture the services it’s providing for patients and get paid – saving hospital resources, time, and money.