Post on 05-Jul-2020
Emergency Department Case Managers
Impact Transitions of Care
Presented By: Sue Jester, RN, BSN, CCM
Matt Biondo-Smith, RN, BSN
Alyssa Frisbie, RN, BSN
Date: June 18, 2019
Reflection
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“In any given moment we have two options: to step forward into growth or to
step back into safety.”
– Abraham Maslow
Developing a Robust Emergency Department
Case Manager (ED CM) Role
Assessment
o A Case for Change
Planning
o Development
Intervention
o A Day in the Life
o Data Driven Modifications
Evaluation
o Case Studies and Outcomes
o From Then to Now
Next Steps
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Developing a Robust Emergency Department
Case Manager (ED CM) Role
Assessment
✓ A Case for Change
Planning
o Development
Intervention
o A Day in the Life
o Data Driven Modifications
Evaluation
o Case Studies and Outcomes
o From Then to Now
Next Steps
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Assessment: A Case for Change
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• Keeping up with current health care trends
• Forecasting changes on the horizon
Assessment: A Case for Change
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Emergency Department (ED) Overview:
• ~250 patient visits/day
• 5 physician teams
• Psychiatric access workers
• Medical Social Workers in Senior ED
• Patient Resource Managers
Identifying the Gap
• Medical necessity documentation
• Readmission analysis and prevention
• Observation expertise for patients and staff
• Diversion/Redirection
Assessment: A Case for Change
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Developing a Robust Emergency Department
Case Manager (ED CM) Role
Assessment
✓ A Case for Change
Planning
✓ Development
Intervention
o A Day in the Life
o Data Driven Modifications
Evaluation
o Case Studies and Outcomes
o From Then to Now
Next Steps
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Creating a Partnership
• Be visible
• Be accessible
• Build rapport
• Learn together
Planning: Development
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• Interview panel with all stakeholders
• Desired qualities:
• Critical thinking
• Communication skills
• Engaged and energetic
• Leadership skills
• CM experience not required
Planning: Development
November 2015
• Staggered implementation
• Rotating/overlapping shifts
• 8am-8pm and 2pm-2am
Planning: Development
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Planning: Development
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• Orientation
• Creating Connections
• Building a Toolkit
Planning: Development
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• Building a Toolkit
Planning: Development
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Developing a Robust Emergency Department
Case Manager (ED CM) Role
Assessment
✓ A Case for Change
Planning
✓ Development
Intervention
✓ A Day in the Life
o Data Driven Modifications
Evaluation
o Case Studies and Outcomes
o From Then to Now
Next Steps
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• Follow-up on yesterday’s discharges
• Determine which patients to see
• Field calls from the community
Intervention: A Day in the Life
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Process for Selecting Patients:
• “Potential Admission” list
• “Potential Readmissions” list
• Interqual
• Electronic referral process
• Tracking our intervention
Intervention: A Day in the Life
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Intervention: A Day in the Life
• Safe housing
• Health insurance and access
to health care
• Social support (caregivers)
• Transportation
• Socioeconomic conditions
affecting ability to pay for
medication(s)
• Education and linking with
community resources
• Older adults
• Patients without established
medical care teams
• Complex care needs
• Patients that delay or refrain
from following-up after
discharge
Focused Patient
Populations
Social and Physical
Determinants of Health
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Benefit to Seeing ED Patients with Plan for Admission:
• Begin the discharge planning process while patient and family are present and captive listeners
• Setting the tone; letting the patient/family know the goals of admission and anticipated length of stay (LOS)
• Forecasting barriers early and communicating this to the hospital team, which decreases LOS
• “Mining Resources” from complex patients
Intervention: A Day in the Life
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Maintaining Relationships
• Visiting community partners
• Collaborating with complex care
• Department and hospital meetings
Intervention: A Day in the Life
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Developing a Robust Emergency Department
Case Manager (ED CM) Role
Assessment
✓ A Case for Change
Planning
✓ Development
Intervention
✓ A Day in the Life
✓ Data Driven Modifications
Evaluation
o Case Studies and Outcomes
o From Then to Now
Next Steps
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Interventions Monthly AveragePatients Redirected 67
Readmission Avoided 32
Medication Assistance Provided 34
Discharge Planning Started 129
Specialist Appointment Set UP 83
PCP Appt. Set up 95
Homecare Set up 46
Hospice arranged 5
SNF Placement 13
Transportation Arranged 45
Care Coordination 540
Interventions: Data Driven Modifications
ED CM Interventions
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©2015
Intervention: Data Driven Modifications
Adding to the Toolkit
• One of the first pieces of DME
stocked in the ED was the front-
wheeled walker
• Helpful for weak patients with unsteady
gait; many times patients can discharge
home rather than be admitted for a PT
evaluation
• However, there are exceptions including
patients with a fall on outstretched arm
(FOOSH)
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• After meeting with physical therapy,
we asked our DME supplier to
stock hemi side walkers
• ED CM has been able to divert
patients with arm injuries who
required the use of a walker, but
were unable to do so with the
injured arm
Planning: Data Driven Modifications
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Recognized Problem:
• Patients improved in the ED following breathing treatments,
but the provider had concern for bounce back after discharge
Creative Solution:
• Collaborated with stakeholders and obtained ED supply of
NMT machines
©2015
Planning: Data Driven Modifications
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Pre-ED CM:
• Admit for MRI and possible neuro-spine consult
Current:
• ED CM facilitates outpatient MRI exam with results to
primary care physician and close outpatient specialist follow
up
©2015
Planning: Data Driven Modifications
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Developing a Robust Emergency Department
Case Manager (ED CM) Role
Assessment
✓ A Case for Change
Planning
✓ Development
Intervention
✓ A Day in the Life
✓ Data Driven Modifications
Evaluation
✓ Case Studies and Outcomes
o From Then to Now
Next Steps
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• 92 yo female
• Patellar fracture s/p fall
• 2 prior ED visits and 1 OBS stays at 2
different hospitals
• Family was having difficulty managing
care at home
• This ED visit, CM identified a payor
source for SNF
• Successful placement to SNF from the
ED, preventing unnecessary
admission
Case # 1: We Can’t Take Care of Mom Anymore
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Evaluation: Data
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• 80 yo male, UTI with MDRO
• Discharged home from inpatient
hospitalization with prescription for
fosfomycin
• Returned to ED d/t inability to afford
medication
• ED CM collaborated with pharmacy
and obtained a prior-auth, allowing pt
to fill medication at affordable cost
• Prevented readmission by helping
obtain the appropriate medication
Case #2: I Can’t Afford My Medication
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Evaluation: Data
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• 68 yo female
• Discharged from IP stay s/p hip surgery to SNF earlier that day
• Left AMA from SNF and is now in her home
• Pt called EMS d/t difficulty
getting to the bathroom
• ED CM coordinated care over
the phone, found safe plan
Case #3: Help! I Can’t Get to the Bathroom!
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Evaluation: Data
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• 91 yo male, recently discharged
from 3-night IP stay to home
• Once home, couldn’t get up from
chair due to weakness, called EMS
• Patient requested admission to
allow time to arrange 24/7 private
duty care
• ED CM assisted in arranging
private duty care from the ED
Case #4: I Need More Care at Home
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Evaluation: Data
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• 78 yo female
• History of COPD with recent hospital admission
• Returned to ED for shortness of breath
• ED MD planned on admission
• Patient wanted to discharge home
• Same day pulmonology appointment
• Oxygen arranged
• Oxygen supplier accompanied patient to the pulmonology office
Case #5: I Want to Go Home
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READMISSIONS AVOIDED
Readmissions
Avoided
450
PER
YEAR
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2016 2017 2018
# ED Patient
Visits88,845 89,618 88,721
# Patients seen
by ED CM7,247 8,941 9,802
% Patients seen
by ED CM8.2% 10.0% 11.0%
Evaluation: Data
ED CM Impact Over a Continuum
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Evaluation: Data
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Evaluation: Data
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Evaluation: Data
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Developing a Robust Emergency Department
Case Manager (ED CM) Role
Assessment
✓ A Case for Change
Planning
✓ Development
Intervention
✓ A Day in the Life
✓ Data Driven Modifications
Evaluation
✓ Case Studies and Outcomes
✓ From Then to Now
Next Steps
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November 2015
1. ED CM approached hesitant providers
2. Enthusiasm from providers for simple ED CM interventions
3. More time spent checking interqual and reviewing medical documentation
4. Started with basic discharge interventions
5. The ED provider admitted patients because “they can’t walk”
June 2019
1. Provider approaches the ED CM with potential discharge needs
2. Expected that ED CM will be involved and be successful
3. Majority of ED CM time is utilized by finding alternatives to admission
4. Have more complex plans, using multiple resources
5. ED providers now ask ED CM about safe alternatives
Evaluation: From Then to Now
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• Developed interdisciplinary relationships, expanded our
toolkit, and discovered new methods for alternative
dispositions
Evaluation: From Then to Now
Developing a Robust Emergency Department
Case Manager (ED CM) Role
Assessment
✓ A Case for Change
Planning
✓ Development
Intervention
✓ A Day in the Life
✓ Data Driven Modifications
Evaluation
✓ Case Studies and Outcomes
✓ From Then to Now
Next Steps
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• Continuing to identify needs and resolving them in a
systematic way
• Working toward 24-hour outpatient appointment scheduling
• Enhancing collaboration with our Community Paramedics
• Making DME available after hours and on the weekends
• Discovering community resources through networking and site
visits
Next Steps
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• Improving communication with primary care providers and case managers
• Updating tools from paper to electronic
• Obtaining clerical support
• Initiating community outreach and education, specifically for long-term care planning
Next Steps (continued)
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OUR TEAM: Small But Mighty!
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Thank You ED Leadership for Your Time and
Support of this Program
Dr. Robert McCurdy, SJMHS Leadership/EPMG
Dr. Daniel McGillicuddy, SJMH Leadership/EPMG
Dr Kathryn Volz, SJMH Leadership/EPMG
Jennifer Dunn, RN, Nursing Director ED for SJMHS
Greg Morman, RN, ED Nurse Manager
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Special Thanks to Our Director and Acute Care
Flow Team Leaders For Their Vision and Daily
Encouragement to Find Creative Solutions for
Our Patients
Tarun Abraham, MD MHSA, Director, Acute Care Flow
Rhonda Keith, BSN, Manager, Acute Care Flow
Sarah Brown, LMSW MHSA, Operations Manager
Bryan Gaines, MSE, Operations Manager
Special Thanks
References
CMSA Standards of Practice
ACMA Compass Directional Training:
https://www.acmaweb.org/Compass/compass_main.aspx
Social Determinants of Health 101 for Health Care Five Plus Five, by Sanne
Magnan Oct 9, 2017/discussion paper
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