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Mentor moment: A holistic approach to ED case management

Case Management Weekly, June 16, 2010

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The emergency department (ED) operates 24 hours a day 365 days a year. Providing unscheduled episodic care requires close monitoring to ensure economic viability because of the volume of uninsured/underinsured patients and third party payers’ penchant to deny payment for services they believe lack medical necessity.

The ED is a major source of inpatient admissions and serves as the fundamental base for establishing medical necessity. An ED case management model promotes complete and accurate clinician documentation in the health record and establishes a foundation for promoting proper inpatient admissions.

The decision to admit a patient to the hospital is complex. The right decision requires that  hospitals embrace physician clinical judgment, clinical acumen, and medical decision-making far beyond admission screening criteria. Consider the following excerpt from Chapter 1 section 10 of the Medicare Benefit Policy Manual :

The physician or other practitioner responsible for a patient's care at the hospital is also responsible for deciding whether the patient should be admitted as an inpatient. The decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient's medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital's by-laws and admissions policies, and the relative appropriateness of treatment in each setting. 

Factors to be considered when making the decision to admit include such things as:

• The severity of the signs and symptoms exhibited by the patient;
• The medical predictability of something adverse happening to the patient;
• The need for diagnostic studies that appropriately are outpatient services (i.e., their performance does not ordinarily require the patient to remain at the hospital for 24 hours or more) to assist in assessing whether the patient should be admitted; and 
• The availability of diagnostic procedures at the time when and at the location where the patient presents.

Practical incorporation of documentation principles

In a previous blog, I discussed the merits of specific, accurate, and detailed clinical documentation that reflects patients’ severity, acuity, risk of morbidity and mortality, as well as physicians’ clinical judgment, clinical acumen, the amount of work performed, and clinical medical decision-making.

Taking one step back, let’s approach clinical documentation in the mind of the physician. The patient receives an appropriate EMTALA screening and subsequent care begins.

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