The Clinical and Bottom Line Case for ED Case Management

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.

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.

Therefore, incorporating case management programs in the emergency department is key to preventing claim denials due to medical necessity and maximizing reimbursement. Case managers in the ED support the financial well-being of the hospital by working with clinicians and payer medical directors to adhere to hospital and regulatory policies and verify admission criteria, arrange transfers to other care settings, coordinate community resources, and ensure proper documentation for these interventions.7

Making The Case For Case Management In The ED

As you can see, there’s a clear benefit to an ED case management program, but what’s the right approach, and how should a hospital move forward in bringing in the appropriate staff, providing the right training, and establishing new procedures?

First it starts with data. At Lee Memorial Health System, they were able to not only document a $4.5M ROI, but when the program was eliminated due to budget cuts, revenue was impacted because of inappropriate admissions, patient flow stalled, patient satisfaction scores dropped, and the emergency department nursing staff reported being overworked because they were dealing with social issues. So, they received approval to staff the ED with case management resources 14 hours a day, 7 days a week. “We looked at our peak times for admissions in order to place case managers and social workers in the emergency department to screen as many patients as possible” 8

In the most effective case management programs, it also begins with leadership. That’s how Florida Hospital in Orlando adopted an ED case management program. Dr. Eugene Truchelut, Medical Director of Florida Hospital Orlando’s Population Health Service Division sought to address the increasing overcapacity situation by launching a series of pilots focused on improving the use of evidence-based criteria, and pairing RN case managers with ED Physicians 24 hours a day so they could collaborate in real time. The two pilot programs saved about 343 bed days in 15 weeks and resulted in more than $274,000 in cost savings.9 Needleless to say the Florida Hospital Orlando administration welcomed the results of the initial pilots and funded the project to continue.

ED physicians also see the value of a well-run program. “I love going to a patient’s clip board to begin my decision making and getting surprised to see a report from our case manager listing out the admission criteria that were met or suggesting that the patient may be a candidate for home nursing care,” says Dr. Silverman, Chairman of Emergency Medicine at the Virginia Hospital Center.10

Even though “ED physicians have become the gatekeepers for about half of U.S. hospital admissions, including two-thirds of those that are not elective11,” many hospitals still lack ED case management programs, and the reasons are most often cited as insufficient staff and a lack of commitment from financial leadership, based on a survey conducted by Change Healthcare12. In addition, although many hospitals do have case managers in their ED, the survey found that less than a quarter staff them on a 24/7 basis.

So how do you tackle the staffing challenge? Existing resources can be temporarily reassigned to prove out the value of a program, and social workers can be leveraged to augment the RN case managers. Technological advancements can also be deployed to make ED case managers more efficient, from mobile technology to allow for better distribution of resources, to workflow integration and automation to reduce administrative tasks. In the end, hospitals need to invest in change; the ROI is clear. With 24/7/365 coverage in the ED, everyone benefits — your hospital, your clinicians, your patients, and your community.

1. Relias Media (July 2018) "Case Management Insider: Roles and functions of ED case manager"
2. Health Intelligence Network (April 2011) "Best Practices in Contemporary Case Management: 8 Roles of the ED Case Manager"
3. Emergency Physicians Monthly (July 2018) "Adding a Case Manager to Your ED Line-Up"
4. LA Biomed (December 2016) "Study: More than Half of ICU Admissions May Be Inappropriate"
5. Health Intelligence Network (April 2011) “Best Practices in Contemporary Case Management: 8 Roles of the ED Case Manager”
6. Relias Media (August 2011) “ED case managers save $4.5 million”
7. Becker’s Hospital Review (July 2018) “Aligning Case Management Processes With the Revenue Cycle”
8. Relias Media (August 2011) “ED case managers save $4.5 million”
9. Change Healthcare (2017) “A Collaborative Approach in the ED Reduces Inappropriate Admissions”
10. Emergency Physicians Monthly (July 2018) “Adding a Case Manager to Your ED Line-Up”
11. https://healthcare.dmagazine.com/2014/03/12/the-hospital-emergencydepartment-is-now-the-admissions-department/
12. https://www.changehealthcare.com/resources/detail/ed-casemanagement-survey-report