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Book excerpt: Case management in the ED, Part 1

Emergency Management Alert, September 25, 2007

"Case management in the ED has become more than classic social work or discharge planning," say Kathleen Walsh, RN, MS and Karen Zander, RN, MS, CMAC, FAAN in their new book, Emergency Department Case Management. Here is a look at the evolving role and function of the ED case manager. Next week: How the ED CM fits into the hospital CM service at large.

[T]he clinical staff in the ED benefited for many years from the expertise of social workers and behavioral health evaluators. However, major changes in the industry have created a need for officially adding personnel with the title "case manager," or restructuring the work currently completed by social workers and others to create a more comprehensive CM service.

As EDs began to deal with the need for improved flow and capacity, as well as the need to accurately place patients in observation status or inpatient status, hospitals tried to cope by teaching nursing staff how to evaluate patients. This new responsibility on top of staff members' clinical responsibilities was understandably overwhelming and often perceived as inappropriate because, for example, staff nurses' role was made even more difficult when physicians did not cooperate or when billing status became intermingled with bed placement problems. Separate clinical decision/observation units sometimes helped clarify the problem and provided somewhere to put patients whose condition was ambiguous and evolving, but they did not completely remove the need to assign a billing status. Although policies such as assigning observation status should be familiar to staff nurses and other personnel, hospitals have begun to see the need to assign one group-usually CM-accountability for accuracy in the ED.

CM in the ED has become more than classic social work or discharge planning. It has grown into the primary method used to address and divert patients who are not sick enough to need an acute care bed but are at too much risk (physically, psychosocially, or mentally) to be sent back to their homes immediately following the ED encounter. Case managers live and work in the gray area between these two extremes. They also do whatever they can to help staff members keep patients moving. Because of the plethora of needs that the community brings into the ED setting, it makes sense to have both sets of professional expertise available in some combination of coverage during ED "prime time."

The inclusion of RNs as case managers for the ED has been gradual. However, it is becoming the predominant model, due to a variety of factors that will be addressed later in this text. The main factor is the need to deal with the ever-increasing volumes of patients coming to EDs-from patients who are near death to patients who may not require inpatient admission at all. It is our belief that if an ED has more than 35,000 visits per year, a full-time case manager is warranted.
In addition, the acuity of ED patients has increased over the past several years. In fact, a large healthcare database substantiates that the number of high-complexity Medicare patients nearly doubled between 2000 and 2004, while low-complexity visits declined in those years (Savafi, 2006). As a result, ED case managers are intervening at both the entry to and the exit from the ED, as well as during the ED stay. Thus, there are currently a variety of responsibilities and roles for the ED case manager, a few of which are described in the following sections.

Case manager as expeditor
One type of ED CM role is as an expeditor, such as the RN care facilitators at Brigham and Women's Hospital in Boston. These RNs are armed with cell phones and respond to outside [calls from] hospital EDs and physicians' offices to ascertain whether patient should be taken directly to cardiac catheterization or other services. The patient's disposition is discussed with the ED medical director or the surgical specialty attending physician, and the patient is sent to the appropriate area upon arrival. 

Access care manager
Another role in ED CM is an RN access case manager who approves all direct admissions and admissions from the ED into the hospital based on criteria and, if needed, negotiation with the referring physician as well as the ED (see Appendix A for Direct Admission Process). Eventually, hospitals large and small will incorporate this kind of decision-making by ED case managers in collaboration with medical directors and hospital administrators for all comers, including acute-to-acute transfers.

Case manager as clinical specialist
To provide the kind of assessment that is aimed at decreasing the "demand" for inappropriate medical interventions/hospitalizations, ED CM professionals must be knowledgeable about disease states and trajectories, mental and physical functional abilities, and levels of nursing care available in the patient's community. In addition to having a background in reimbursement and medical necessity criteria, RNs are being increasingly utilized as case managers because they can be more clinically connected with the staff RNs and technicians. RNs are also generally more comfortable than social workers with proactive dialogue with physicians before physicians have determined the final disposition. One nurse manager of an ED, commenting on these skills, said, "We [the nursing staff] are so relieved that we have a case manager, because otherwise we would feel guilty not admitting the patient."

Clinical staff in EDs have benefited for many years from the expertise of social worker and psychiatric evaluators. However, as described earlier, major changes in the industry have created the need for officially adding case managers to fill these necessary roles or restructuring the work currently completed by social workers and others to create a more comprehensive CM service.

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