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Book excerpt: Case management in the ED, part 2

Emergency Management Alert, October 2, 2007

ED CM is a specialty within acute care CM. CM employees should be on the same salary and benefit scale as the rest of the department. However, although the CM personnel assigned to the ED are part of the larger service, their positions should be protected to allow them to maintain concentrated coverage for the ED. Although it may be reasonable to combine ED coverage with intensive care unit coverage or coverage of a similar area in a small hospital, it would not be wise to spread coverage in a medium to large hospital with high ED volumes. These are just some of the considerations when dovetailing commitments to the ED with the needs of the larger hospital and CM service.

A typical CM department structure includes a range of roles, some combined and some distinct, including:

 Director or manager
 Physician advisor or medical director
 RN case managers
 Social workers
 Denials/appeals specialists
 Administrative assistant for the department
 Coverage for weekends, holidays, and PTO
 Case aides, documentation specialists, case managers in admitting (depending
on the model)

Caseload numbers per FTE and assignment patterns vary within every organization. The most reasonable guide to compare and contrast FTEs is to use the overall case mix index (CMI) as a proxy for the complexity of the organization and patients' conditions. The amount and type of liaison staff, role and level of social workers (e.g., having bachelors or a masters degrees), presence of on-site payers, structure of medical staff, and type of technology/software all have bearing on number of FTEs and how personnel are deployed.

Placing case managers in an ED usually comes several years into the development and transformation of a CM department or service. Appropriations for the position occur when two realities merge:

1. The hospital becomes concerned about flow and capacity issues
2. The hospital accepts it place as the center of the community for both medical and related social problems

As the organization realizes that "case managers connect the boardroom with the bedside," it becomes willing to establish a full contingent of social work and RN staff in all care settings, including the ED. As a result, CM professionals have the opportunity to create a practice firmly based in authority, social power, and influence (Zander, 2000; French and Raven, 1959).

Being an active part of the entire department is essential for ED case managers and social workers. The work can be very isolating unless there are continuous connections with the director, peers, physician advisor, and others. What is most important is the handoff of vital information between the ED CM/social worker and the nurses, physicians, and others to whom he or she transfers the patient, whether internally or externally. ED case managers also should be assigned to quality improvement teams, throughput task forces, and DM programs.

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