1. Kecia Cowden RN, BSN Graceland University
Emergency Department Case Management: Developing a Job Description Incorporating Evidenced Based Interventions
Kecia Cowden RN, BSN
Graceland University

2. “Kecia,
How would you feel about transitioning to the emergency department to do case management,” asked Ann? (Director of Care Coordination).
In October 2008, I was asked by my director, Ann, to transition to the emergency department to do case management.
Mercy Emergency Department

3. My first thought was….
“Of course I want to do that! That is I did my role transition project on for school.”
(How to transition from role as staff nurse to role of nurse practitioner in the environment that I will be working.)
I was very excited to be asked to partake in this new initiative for my organization. I had prepared for such a transition as a part of the graduate program here at Graceland University.

4. My second thought was….
As prepared as I was, I still was a little apprehensive about leaving what was “known” to me.
Yikes! That means I have to leave my friends, the comfort of “knowing of my job,” and in an area that I am considered an “expert”!

5. This is going to be a leap of faith
But had faith that I could do it.

6. My next thought was… I can do this…
I started right in on brainstorming
What was known about the role:
1. Need to review for medical necessity in preparation for the RACs
2. Work with Iowa Care patients
3. BUT, how else could a case manager impact the ED environment?
The first step was establishing what I did know. The role needed to help assure medical necessity in preparation for Recovery Audit Contractor reviews as part of Centers for Medicare and Medicaid Services. It also needed to assist with the management of Iowa Care patients. Iowa Care is an insurance program in the state of Iowa to help those who don’t qualify for Medicaid. They can only obtain health care at certain hospitals in the state and my hospital is not one of them.

7. Care Coordination Department
I KNOW inpatient case management
I don’t know the ED, but the ED staff does!
Clear that an observational job analysis would be needed to explore ways that a case manager could impact an unknown or unfamiliar specialty area.
Arranged for an “orientation period” across the ED continuum of care.
I recognized that while I did know how to do case management at the inpatient level of care, I didn’t know the emergency department well enough. The ED staff does know the environment so clearly I needed to do analysis of how case management could best be served for this specific environment. Performed the analysis during an “orientation period” across the ED continuum of care.

8. Orientation
Spent time in triage, fast track, and with health care access representatives.
Introduced the “general” case manager role to ED staff and physicians then sought input on how they viewed a case manager could assist.
Got to work!
I educated the ED staff about case management and they in turn introduced me areas that they needed assistance with.

9. Identified the following areas:
Chronic disease management in the ED by uninsured
Homeless patients using the ED
Concerns related to multiple visits or re-presentations
High census alert/ ED throughput issues
Multidisciplinary team issues
Need for critical thinking/autonomy/research skills and attributes/ knowledge of community resources
Identified the areas on the slide.

10. Review of Literature Statistics: 1996-2006
CDC National Center for Health Statistics report: Number of medical visits to offices, hospital outpatient and ED increased by 26 percent.
ED served as route of admission for one-half of non-obstetric hospital admits (up from 36%)
82/100 Medicaid patients use the ED more frequently than private insured (21/100).
ROL: The number of individuals accessing the emergency department have increased. The ED serves as an access point to inpatient care in ½ of nonobstetric care. A large portion (82/100) of Medicaid patients use the ED more frequently that the private insured (21/100).

11. ROL: Chronic disease management
In a study by Decker, Schappert, & Sisk (2009) for the top eight chronic health conditions (Heart disease, cancer, Cerebrovascular disease, chronic lower resp., arthritis, HTN, DM, and depression) the percentage of visits to the ED was higher for those with Medicaid, Medicare, or no insurance compared with private insurance.
Case managers can assess those patients utilizing the ED for chronic care and assure referrals and encourage compliance
The next few slides show portions of the literature review results. Essentially, I reviewed the literature for each of the four main body of topics, abstracted the evidenced based interventions that were successful in each category, and placed them in the job description for the emergency department case manager. The rough draft of the job description was then presented to the ED chain of command who then completed a questionnaire regarding the usefulness and pertinence of the job description in defining the new role for this initiative.
Chronic disease management: Of the top chronic diseases, the percentage of visits to the ED was higher for those with government insurance compared to those with private insurance. Case managers can assess those patients utilizing the ED for chronic care and make appropriate referrals, assess the utilization patterns, and provide a holistic discharge plan.

12. Case in point 54 year old uninsured, homeless male
Seen in ED 9/08- history of seizure disorder known. No referral made to PCP but did get him his seizure meds.
Seizure-> lacerated head 2/09, returned for suture removal in March
Return to ED 4/10/09 and referral called to me. I probably could have avoided these visits if referral made in September!
Filled prescriptions, referral to House Of Mercy free clinic (near Bethel Mission)
In this case a patient was uninsured, homeless, had a chronic health condition and had multiple visits to the ED prior to referring patient to me for case management. I possibly could have avoided the re-presentations which would have help to assure patients safety and continuing health.

13. Homeless
O’Toole, Conde-Martel, Gibbon, Hanusa, Freyder & Fine (2007) length of time a person is homeless significantly impacts health status. Of 230 newly homeless people surveyed, 123 stated they presented to the ED when first homeless. Only 25 had an acute health issue.
Case manager needs to assess homeless patients for resources and chronic disease maintenance
Study showed that when individuals became homeless, 123/230 presented to the ED but only 25 had an acute health care need. Case manager can impact the health care in these individuals with referrals to free clinics and pharmacies.

14. Emergency department throughput
Howell, Bessman, Kravet, Kolodner, Marshall, & Wright (2008) cited the Institute of Medicine’s 2006 report which determined that 91% of ED are crowded and beyond capacity leading to “census alerts,” diversions and the crucial need for improved throughput.
Can be achieved with decreasing LOS and improved turnover of inpatient beds (Underwood, 2007; Lees, 2008; Howell et al., 2008).
Case manager can assist with throughput by assuring medical necessity, decreasing LOS by initiating discharge plan and assessment…..

15. Continued:
Adequate D/C preparation and monitoring of appropriateness of admission and continued stay review can also impact throughput (Lees, 2008; Moss et al., 2002; Carroll & Dowling, 2007).
“Full Immersion Case Management”
( depending on unit)
Multidisciplinary approach crucial but majority done by the patient care managers.
The ED case manager then assists with transition to the Inpatient case managers who picks up with continued stay review, and utilizes a full immersion case management model in which is an evidenced based method that decreases LOS.

16. Communication!
Communication is key to throughput, of course this is not a new concept!
Very important to communicate an estimated D/C date to patient and family.
A date makes discharge more real and far less abstract.
Providing a goal LOS in the ED can help with the D/C occurring timely.
Milliman provides a goal LOS and can be communicated.
Communicating an anticipated LOS to patient and family helps the date become goal and therefore less abstract (such as “We anticipate your being discharged on Wednesday or Thursday…..” versus “when you go home…”

17. Observation patients Communicating probable discharge the next day.
Prepare patient and family to be ready.
Start the planning before makes it to the room-request PT/OT/ and even social services from the ED
Establish needs to D/C such as HHC etc.
* We are monitoring through Six Sigma Black Belt
Very important to clearly state anticipate discharge tomorrow “if everything checks out ok” or “symptoms resolve” so that family is ready to take home etc. and can make arrangements to get them there.

18. D/C planning and Adverse Outcomes
Older persons considered vulnerable, or at risk for adverse outcomes. Repeat visits, hospitalization, or death within 90 days.
Three studies: Interventions affected outcomes
1. Hastings et al. (2007) Veteran’s Medical Facility >65 y/o (n=942). More than 1 in 3 veteran’s experienced adverse outcome (n=320) within 90 days. Majority of repeat visits within 30 days.
Next few slides show the evidence that discharge planning helps to reduce adverse outcomes.

19. Continued:
2. Dunnion & Kelly (2005) studied communication between ED physician and PCP and certainly HHC at discharge from ED. Poor communication leads to poor continuity and medication errors.
Qualitative study
Respondents felt a “liason” or care coordinator in that role would greatly impact care. (continuity of care)
Liason between hospital and outpatient setting helps to prevent errors, allows for continuity of care, and assists with transitions across the continuum.

20. Continued: 3. Hegney et al. (2006)
Risk screening by trained individual resulted in a decrease in re-presentation
Risk screening >70 y/o (n=2139)
16% reduction in re-presentation rate, 5.5% reduction in readmission rate. Decrease in ALOS from 6.17 days to 5.37% (comparing 10/2002 and 6/2003).
Decrease in the “Frequent flyers” (>/= 3/m)
Risk screening helps identify the patients that case managers can work with to decrease adverse outcomes.

21. “Frequent Flyers” No primary care providers OCD patients (DVD)
“Drug seekers” (MB, CC)
Alcohol detox (RB)
Literature Describes “frequent flyer” as greater than or equal to 3 visits per month. I prefer not to place boundaries and would like a referral on any patient that the physicians and nursing staff feels could benefit.
The frequent utilizers have various chronic conditions and seek the ED for various concerns such as seeking drugs, alcohol detox, or have no providers.

22. Success! Partnering with Payer
I started 10/08

23. Case in point…
I started case managing this patient Nov. ‘08

24. Multidisciplinary team approach
Auslander et al. (2008) and Moss et al. (2002) indicated that health needs more often met than social needs.
Dedicated social worker can help with homeless, those who lack resources, community referrals, etc. leaving the nurse case manager to work with admission criteria, medical necessity, and level of care issues (ED Case Management, 2005).
Literature establishes that a multidisciplinary team better prepares a patient for discharge into the community with appropriate referrals.

25. Team Approach Facilitate return to community
Prevent unnecessary and/or inappropriate hospital admissions (“easier to admit than send home,” patients)
Decrease re-presentations
Provide safe and effective discharge from the ED (PT evaluation/screening)
(Moss et al., 2002; Hastings et al., 2007; Romania, 2006; Carroll & Dowling, 2007; Walsh et al., 2003)

26. APN as Case Manager
White and Hall (2006)- stated that preparation at a graduate level is becoming more emphasized for case management. Competencies associated with the graduate level of preparation corresponds with the increasingly complex role and additional responsibilities of the nurse case manager.
AACN-APN’s plan and coordinate multidisciplinary interventions, initiate and facilitate change in an organization, facilitate the conduct and utilization of research
Increasingly complex role, additional responsibilities, need for planning and coordinating of multidisciplinary interventions, driving new organizational initiatives through research (next slide)

27. AACN continued Provide clinical consultation in specialty areas
Apply ethical and legal principles to complex health care circumstances (1998).
All above tasks are associated with the development of a case management model of care and associated job description for an ED environment.
Providing clinical consultation in specialty areas, applying ethical and legal principles to complex health care circumstances, calls for a graduate level of education as minimal education requirement

28. Case Management and RACs
Case managers have ability to impact LOS
Assure medical necessity
Control utilization of services
Improve documentation that supports acute needs.
Case managers are in the unique position to help the organization slide through the audits unscathed, or at least reduce the amount of loss
Case managers create initiatives for the organization to prepare for RAC audits.

29. Barriers Acceptance by physicians
(Physicians need to understand that often it is about the level of care, not whether can be in the hospital or not)
Case managers busy taking care of and addressing the “social issues.”
ED staff knowledge related to case management and role
Through the application of a qualitative research analysis, the job description was finalized. As time allows, I will outline the steps of creating the case management model of care that the job description supports.
First the barriers:
Barriers to establishing a case management model of care: physicians acceptance, tied up with non-nursing activities, lack of understanding by the ED department staff.

30. Barriers: Patient Related
No identified “Risk screening process”
Identifying the “frequent utilizers” for referral
A system to alert staff and physicians patients that are being “case managed” and have a “care plan.”
Frequent utilizers without a managed care provider
IOWA CARE Insurance program
Hospice referrals (GL)
Established the patient related barriers.

31. So, where to now? Case manage the “frequent utilizers”
Develop care plans that are placed in a central location. Meet monthly with ED providers to update on status
Become proficient at CBT (for DVD)
Develop a unique “model”
Strengths: Strong and supportive leadership
Partnership with “lock in” program
Developed a plan to overcome the barriers.

32. Where we are going…
State Case Management Society of America presentation
Poster presentation at National level?
Present at Mercy Evidenced Based Practice “Grand Rounds” (working with J. McCleish) scheduled for August.
Looking towards the future with the model of care and disseminating the research project outcomes.

33. Sustainment and Measurability
Number and cost of Iowa Cares patient visits
Number of ED visits by patients using ED for Primary Care
Number of In-Patients with 1 day Length of Stays admitted through the ED
Number of Observation patients converted to In-Patients admitted through the ED
Established method of measuring the outcomes ongoing

34. Six Sigma Partnership Create reports for each metric
Develop goals for each metric
Create score card
Partnered with a Six sigma team and established “metrics” to be monitored

35. Iowa Care
I started this position 10/08 and impacted these patients from beginning!

36. Iowa Care and associated costs

37. Suggestions?
Comments?
Concerns?

38. Conclusion
Development of a job description that pertained to this ED that then bridged and augmented the development of a case management model of care was merely a stepping stone in the advancement of evidenced based intervention practice.

39. Cont’d
The goal of the project was merely to establish an evidenced based intervention JD; however the affects are more far reaching. The end result is to improve the success of the patient/clients and their families outside of the ED environment, thus improving their lives.
Theoretical framework: Dr. Mary Naylor’s Transitional Model of Care and Boykin and Schoenhofer’s Nursing as Caring philosophy.

40. Model of Care
Patient centered; patient is unique in his/her own learning and growing environment; one most “know” the person to care.
Patient is unique in discharge needs, must understand the person/relationships/resources/ to create a discharge plan. Resiliency vs. Vulnerability! The new “catch phrase.”
The Care Coordination team
Outside resources

41. Case Management Model of Care for Mercy Medical Center DSM
Patient at the center
Care Coordination Team
Outside Resources

42. References
Auslander, G.K., Soskolne, V., Stanger, V., Ben-Shahar, I., & Kaplan, G. (2007). Discharge planning in acute care hospitals in Israel: Services planned and levels of implementation and adequacy. Health and Social Work, 33(3), Retrieved January 10, 2009, from EBSCOHealth Source: Nursing/Academic database
Centers for Disease Control and Prevention. (2008). Americans make nearly four medical visits a year on average. Retrieved February 21, 2009, from
Decker, S., Schappert, S.M., & Sisk, J.E. (2009). Use of medical care for chronic conditions. Health Affairs, 28(1), Retrieved January 10, 2009, from EBSCO Health Source: Nursing/Academic database.

43. References
Dunnion, M.E., & Kelly, B. (2005). From the emergency department to home. Journal of Clinical Nursing, 14, Retrieved January 12, 2009, from EBSCO Health Source: Nursing/Academic database
Hastings, S.N., Schmader , K.E., Sloane, R.J., Weinberger, M., Goldberg, K.C., & Oddone, E.Z. (2007). Adverse health outcomes after discharge from the emergency department- incidence and risk factors in a veteran population. Journal of General Internal Medicine, 22(11), Retrieved January 10, 2009, from EBSCOHealth Source: Nursing/Academic database.
Hegney, D., Buikstra, E., Chamberlain, C., March, J., McKay, M., Cope, G., & Fallon, T. (2005). Journal of Clinical Nursing, 15, Retrieved January 11, 2009, from EBSCOHealth Source: Nursing/Academic database.

44. References
Howell, E., Bessman, E., Kravet, S., Kolodner, K., Marshall, R. & Wright, S. (2008). Annals of Internal Medicine, 149, Retrieved January 10, 2009, from EBSCOHealth Source: Nursing/Academic database.
Lees, L. (2008). Nursing Management, 15(3), Retrieved January 12, 2009, from EBSCOHealth Source: Nursing/Academic database
Moss, J.E., Flower, C.L., Houghton, L.M., Moss, D.L., Nielson, D. A., & Taylor D.M. (2002). A multidisciplinary care coordination team improves emergency department discharge planning practice. Medical Journal of Australia, 177, Retrieved January 20, 2009, from EBSCO Nursing/Academic
Search Premier database.

45. References
O’Toole, T.P., Conde-Martel, A., Gibbon, J.L., Hanusa, B.H., Freyder, P.J., & Fine, M.J. (2007). Where do people go when they first become homeless? A survey of homeless adults in the USA. Health and Social Care in the community, 15(5), Retrieved January 23, 2009, from EBSCOHealth Source: Nursing/Academic database.
White, P., & Hall, M.E. (2006). Mapping the literature of case management nursing. Journal of the Medical Library Association, 94(2), Retrieved January 21, 2009, from