Emergency Department Case Management: Developing a Job Description Incorporating Evidenced Based Interventions

1. 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). 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.)

4. My second thought was…. • 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

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?

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.

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!

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

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).

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

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)

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

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).

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” • (12-14-16-18 depending on unit) • Multidisciplinary approach crucial but majority done by the patient care managers.

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.

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

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.

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)

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)

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.

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).

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

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.

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

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

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)

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

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.

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

34. Six Sigma Partnership • Create reports for each metric • Develop goals for each metric • Create score card

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

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), 178-188. 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 http://www.cdc.gov/NCHS/pressroom/08newsreleases/visitstodoctor.htm • Decker, S., Schappert, S.M., & Sisk, J.E. (2009). Use of medical care for chronic conditions. Health Affairs, 28(1), 26-35. 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, 776-785. 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), 1527-1531. 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, 1033-1044. 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, 804-810. Retrieved January 10, 2009, from EBSCOHealth Source: Nursing/Academic database. • Lees, L. (2008). Nursing Management, 15(3), 30-35. 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, 427-431. 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), 446-453. 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), 99-106. Retrieved January 21, 2009, from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1463029