Placing RN Case Managers in the ED Proves Successful

Better ED quality measures, and, ultimately, greater patient satisfaction are among benefits cited.

The placement of registered nurse (RN) case managers in the emergency department, with a focus on determining appropriate admission status and making status recommendations to admitting physicians, has proven to be very successful at Waukesha Memorial Hospital (WMH) in Wisconsin, a community hospital of 301 inpatient beds and my work home.

I am entering my eighth year as an RN case manager at WMH, with the past four years being assigned to the Emergency Department and Observation Unit. Prior to coming to Waukesha Memorial, I was a community RN case manager working with the Family Care Program of Wisconsin. I received my case management certification in 2016.

Case management in the ED was started here in 2013, primarily with the goal of reducing unnecessary admissions and readmissions. At that time the focus of the case manager was discharge planning – scrutinizing every potential ED admission and identifying those patients who could be discharged to a Skilled Nursing Facility (SNF) for long-term placement or sub-acute rehabilitation. At that time, social workers were no longer used in the emergency department for discharge planning and were reassigned to the inpatient units.

With the introduction of the two-midnight rule by the Centers for Medicare & Medicaid Services (CMS) in October 2013, and the opening of WMH’s Observation Unit in July 2015, admission status became the primary focus of the ED case manager, and it remains as such. Discharge planning evolved into a secondary role, providing an additional layer of support for the emergency department social workers.

WMH has a very focused approach to admission status review and recommendation. Every ED-to-hospital admission is analyzed by the case manager for correct admission status. After reviewing the ED documentation and applying MCG criteria, the case manager then makes the status recommendation to the admitting physician or advanced practice provider. In some instances, a call may be necessary to discuss the plan of care and anticipated length of stay (particularly when considering the CMS two-midnight rule.)

Gathering admission data in the ED can be particularly challenging due to incomplete ED notes, busy physicians, or pending labs or imaging studies. Sometimes, one must make a judgment with just the admitting complaint, available past medical history, and available labs and vital signs. If the admitting physician has not yet examined the patient, he or she may only have a tentative treatment plan or length of stay in mind. (Thank you, CMS, for the two-midnight rule!)

Efficiency in determining admission status relies on the close collaboration between the ED physician, admitting physician, operations coordinator (involved in bed placement), and case manager. This level of coordination helps in the following manners: It ensures appropriate and timely bed placement, better ED quality measures, and, ultimately, greater patient satisfaction.

We have a number of helpful resources available to determine a successful admission status recommendation. Our internal physician advisor (PA) assists with difficult cases, provides education, and promotes collaboration between physicians and case managers. For after- hours cases, or when the PA is not available, we utilize an external physician advisory service. We also have a reference list of the most common observation-appropriate diagnoses, and we rely on MCG admission criteria.

The ED and observation unit case manager’s day does not slow down at 5 p.m. Along with keeping a continued watchful eye on evening admissions, another evening task is to review all patients in outpatient status and those with observation to ensure that status is correct, and when necessary, to contact physicians for status change or observation service orders. The case managers also deliver Medicare Outpatient Observation Notice (MOON) letters as needed.

The benefits of having case managers in the ED include the following:

• ED case managers reduce costly and time-consuming Medicare self-denials. For example: WMH saw a 50 percent decrease in initial ED status-related self-denials and 10.7 percent decrease in overall self- denials in the past two quarters. Self-denials are costly not only in administrative hours and reduced Medicare reimbursement, but also when considering patient satisfaction.
• ED case managers reduce unnecessary admissions and readmissions.
• ED case managers are able to deliver MOON and Advanced Beneficiary Notices (ABNs) in the ED, plus provide proactive patient education and reduction of post-admission grievances.
• ED case managers benefit the patient by ensuring correct admission status and capturing the first inpatient midnight.

My experience as part of ED case management leads me to suggest the following considerations if you embark on this same journey:

• Carve out a work station or office space in what might be an already crowded ED arena. (Keep in mind that ED staff, like all of us, can be quite protective of their territory.)
• Keep in mind that education of physicians, both ED and admitting, and ED staff regarding the role of the ED case manager is crucial for optimal collaboration and success.
• Build rapport with ED and admitting physicians, ED staff, and ancillary staff; this is also imperative. For example, we found that having quick access to willing PT/OT staff for STAT evaluations in the ED was very helpful.  
• Remember that attributes and skill sets for a successful ED case manager include a detail-oriented and analytical personality, clinical experience and confidence in clinical judgement, excellent written and verbal communication skills, exceptional problem-solving skills, the ability to make quick decisions in a fast-paced environment, and strong knowledge of MCG or InterQual admission criteria, depending on which resource you use.

In summary, the case for implementing an ED case manager is strong, and the benefits are abundant. My experience at WMH as an ED case manager has been challenging, fulfilling, and confidence-elevating. I encourage any RN case manager to take on the challenge.

As a manager, if reducing costly admissions, readmissions, and self-denials while increasing patient satisfaction and supporting appropriate hospital utilization efforts is something you want to have in your repertoire, I suggest joining the ED case management movement!