At the completion of this educational activity, the learner will be able to:
- Identify the challenges special populations can present in the ED
- Outline the role of the case manager in the ED
- Describe strategies to help streamline care for special populations, overcome related challenges, and prevent readmissions
EDs have a lot to handle. One in every three Americans will visit an ED each year, and among those are a number of populations that bring special challenges.
These include patients with psychiatric needs (see CMM's related story on this topic in the April 2015 issue), patients with substance abuse problems, and elderly and pediatric patients, said Karen Zander, RN, MS, CMAC, FAAN, president and owner of The Center for Case Management in Wellesley, Massachusetts. Zander spoke during the February 25 HCPro webcast, "Emergency Department Case Management: Manage Challenging Patients and Special Populations."
Many hospitals have added case managers to their EDs in an attempt to meet some of these challenges.
The role of an ED case manager often includes:
- Assisting with level-of-care determinations
- Documenting provider-preventable conditions, including items such as surgical errors, severe pressure ulcers, or mediastinitis
- Smoothing discharge from ED to home health, SNFs, and other care settings
- Developing and implementing case management plans for high utilizers
- Preventing readmissions
Putting case managers in the ED can make financial sense. Lee Memorial Hospital in Fort Myers, Florida, for example, showed an initial savings of $4.5 million when case managers began their work in the ED, said Zander.
Case managers also play a critical role when it comes to the challenging populations mentioned earlier. They can step in to ensure that these individuals not only get the proper care, but also continue to receive the right care once they leave the facility so that they can maintain their health and avoid a readmission.
Webcast speakers Lisa Gawle, RN, BSN, an ED nurse case manager at a level one trauma center in western Massachusetts and consultant for The Center for Case Management, and Heidi Rohloff, RN, MSN, ACNP, an ED nurse practitioner in Detroit and consultant for The Center for Case Management, also discussed various patients that present challenges in the ED and offered some strategies to overcome them during the program.
One of the biggest challenges in any ED are the high utilizers, which Zander has heard are now called "frequent friends" in the spirit of political correctness. These patients may include individuals who have medical issues and underlying psychosocial problems, but may also have drug-seeking behavior and "shop" EDs to get pain medication.
If you encounter patients who fit into this category, don't dismiss their needs. "You need to assess these patients each time they present to the ED with an unbiased approach," said Gawle. "A lot of these patients are coming in for the same condition again and again, some of them daily. But it's important not to get caught up in the history, but really assess them to see if there are other issues going on with the patient that the case manager or the social worker might be able to get involved in to get a sustainable discharge plan."
If you don't screen carefully, a new condition or problem might slip past. For example, one patient, Mrs. C., was a 43-year-old with multiple sclerosis (MS) who visited the ED about 30 times in two months, requesting Dilaudid for pain control. One day she came in complaining of left-sided weakness, which turned out to be the result of a transient ischemic attack, not her MS. Had the clinicians not screened her objectively, they may have missed the problem.
In some instances, a case manager might be able to develop a care plan that can successfully manage a patient's pain condition on an outpatient basis. Case managers should establish consistent care plans so that patients shopping for pain medications understand how their cases will be handled when they come into the system.
"The care plan will direct how their care is going to be managed," said Gawle.
Homeless patients face a unique set of challenges. They often present to the ED with wounds, poor nutrition, and substance abuse problems; in addition, sometimes they have been victims of crime.
The case manager working with a homeless patient needs to assess the social support that's present. Does the patient have a primary care physician? Is there a clinic in the area that the case manager or social worker can link the patient to?
Case managers should also link these patients to area resources for the homeless whenever possible. This may include the Red Cross, homeless shelters, and even friends and family members who might be able to assist the patient.
EDs often count chronic alcohol abusers among their frequent friends, said Rohloff. These patients may be in the ED daily, weekly, or monthly. The standard protocol Rohloff's hospital follows is to hold them until they sober up, she noted.
Whenever possible, refer these patients to community resources and facilitate connections with those resources.
The case manager should actively focus on finding treatment solutions for these patients.
In some instances, he or she might want to consider initiating a civil commitment for alcohol or substance abuse, known as a Section 35, for a patient who is coming into the ED daily.
The case manager should work closely with the attending physician who actually files the motion in court if the patient doesn't have family members to take on that role, said Rohloff.
Case managers must look at the whole picture to ensure they're not missing something going on with the patient, though. "There may be medical issues compounding the problem," Rohloff said. Address them if possible.
Social admits for elderly patients
As baby boomers age, EDs are seeing more social admissions related to safety factors in the home, says Gawle. For example, one case involved an 87-year-old male with dementia living in a mobile home. His wife called 911 because he was acting violent and hallucinating, putting furniture in front of the door to prevent an imagined intruder from coming in.
A situation like this one presents a real challenge for case managers. The patient had Medicare for insurance and no real physical medical issues that could justify a hospital stay. During the ED workup, the information about his home situation came to light, leading staff members to file a claim for an elder at risk.
"These patients are coming in socially, and what we're trying to do is find a sustainable discharge plan," said Gawle.
Enlist financial counselors to identify additional insurance for the patient whenever possible. Getting the patient into a geriatric psych unit or SNF is another option.
"But sometimes we end up holding on to these patients for a long time until we can come up with a discharge plan," said Gawle.
Even with universal healthcare, many patients are still uninsured, said Gawle.
As with the homeless population, case managers must help link uninsured patients to community resources as a way of preventing readmissions. Whether this involves finding them a primary care physician or clinic to meet their needs, obtaining financial assistance for them, or providing them with education, measures to help these patients stay healthy can keep them at home rather than at the hospital.
In some cases, if a case manager can develop a safe, sustainable discharge to home, using a subsidy program to address a patient's needs may be more cost-effective than admitting that patient to the hospital, said Gawle.
One of the major goals for any challenging subset of patients is avoiding problems that can send them back to the hospital after discharge. Find out which patients often return to the hospital and determine why they're coming back to avoid a future problem, said Rohloff.
Develop comprehensive discharge plans to meet these patients' needs. Do they really need a stay in a SNF, or just more physical therapy? What knowledge and resources do the patients need to be functional in their homes? Maybe a home health aide visiting for a few hours a day is sufficient, for example. If it's not safe for the patients to go home, how does the discharge plan address their needs as well as those of their families?
When it comes to ED case management, be proactive with your efforts. Review the patient list each day to determine whether anyone on the list needs case management intervention.
By taking an active role and looking for red flags, case managers will be prepared to address patient needs ahead of time.
Encourage patients and families to discuss their situations in detail to help determine the appropriate level of care, such as a stay in a rehab facility or outpatient physical therapy, said Gawle.
Organizations might also consider setting up specialized EDs to handle different patient groups, such as an elderly-only ED designed to meet the needs of elderly patients and reduce their stress.
A psychiatric ED is another idea to consider, said Zander. A substantial percentage of ED visits, more than 12%, are prompted by substance abuse problems or mental health issues, she said. This percentage might increase as baby boomers, many of whom have been long-time users of alcohol and drugs, continue to age.
When working with patients with psychiatric and substance abuse issues, gaining insurance preauthorization can be a problem.
Case managers need to consider simple factors like making sure a patient is receiving his or her medication while in the ED. A diabetic patient going without his or her medication during an ED stay would be unthinkable, but sometimes psych patients do fail to receive their meds during such a stay, which can make their mental state worse.
Another special population that may benefit from a personalized ED are pediatric patients. While many children come to the ED with injuries, many others come in for respiratory issues.
The case manager's role in a pediatric ED is to:
- Perform thorough assessments
- Link patients with a primary care physician if they don't have one; if they do have one, verify that the physician is a good fit for their condition
- Find subspecialty providers for patients when needed
- Provide social support, for example through transportation programs and WIC, and help patients get access to compounding pharmacies for medication needs
- Work with schools to create action plans for chronic conditions such as asthma
- Identify and address high-risk patient situations
Providing ED services on the road
Some patients call 911 on a frequent basis. Rather than have them come to the ED, MEDSTAR Emergency Medical Services in Fort Worth, Texas, brings the ED to them, using mobile units to check on high-utilizing patients and helping them avoid an ED visit whenever possible.
Instead of an ambulance, the facility sends out a van to these previously identified patients to help meet their needs.
Patients had to agree to enroll in the program, which ended up reducing their 911 calls by half. The program saved $2.8 million in emergency medical services charges and freed up 14,000 ED bed hours, said Zander.
In the future, as more hospitals adopt specialized ways of addressing the needs of complex patient populations, case managers will likely be better able to get patients to the right level of care with the right resources, she said.
Focusing on the special needs of ED patients and identifying the right support to meet those unique needs can improve patient health and reduce reliance on the ED.