TCM 54 November/December 2003

Facing mounting pressures to deliversafe, effective, quality care despite anunparalleled volume in patients, lack ofavailable treatment space, ominous nurs-ing shortage forecasts, and bed restric-tions, EDs struggle to survive.3 Anadded dilemma presents when EDpatient volume exceeds both ED andinpatient bed availability, leading to abackup of patients waiting for an admis-sion bed and those in the waiting roomneeding evaluation.

One solution is to institute case manage-ment (CM) to provide options for dis-charge placement; to work with thehealth care team to improve safe, qualitydischarge to home; to reduce expensesin a cost-sensitive managed care envi-ronment; and to screen high-riskpatients for inpatient versus observationstatus. This article presents one largeteaching hospital’s successful ED casemanagement practice model. Thispatient-centered model focuses on casemanager relationships with patients,families, providers, and payors. This

ith the landscape of health care

rapidly changing, emergency

departments (ED) have been

overwhelmed with patients. For the past several

years, EDs have seen an unprecedented growth

in patient visits. In 2000, the number of annual

visits skyrocketed to more than 108 million

nationwide as patients presented with real or

perceived emergency situations.1 Overcrowding

has led to several problems, including prolonged

waiting times, increased suffering for those in

pain, unpleasant waiting environments, and in

some cases, poor clinical outcomes.2

WKathleen Todd Walsh, RN, MS, CEN, Peter Moran, RN,C, BSN, MS, CCM, and

Christine Greenwood, RN, BSN, CCM, CRRN

model suggests a template for otherfacilities to justify, operationalize, andmaintain a successful CM program inthe ED.

Putting Case Managers in the EDIn the past few years, more health careorganizations have shown interest indeveloping ED CM programs. Much ofthis attention has been spurred with theadvent of the ambulatory prospectivepayment system. This article presentsthe Massachusetts General Hospital(MGH) ED Case Management Model.This 8-year-old model, consistent withcurrent national CM standards of prac-tice, is being emulated by other institu-tions nationwide.

The MGH program was implemented in1995 when a nurse case manager (NCM)was placed in the ED to help educatemedical and nursing staff about admis-sion criteria, necessity of admission, andalternate placement settings. As theposition evolved, two case managerswere added and assigned to day andevening shifts to assess incomingpatients. The goal was to determine theappropriateness of admission and helpthe inpatient case managers initiate dis-charge planning. Over time, the positionhas evolved and begun focusing on

assessing the needs of high-risk ED dis-charge patients, developing appropriateand safe discharge plans, and determin-ing the need for alternate settings. Cur-rently, two part-time and one full-timecase managers staff the program, andhours of operation are 9:00 AM to 7:30PM, 7 days a week.

ED CM ModelThe foundation of practice is based inhealth care relationships. Putting thepatient and family at the center of care,the ED CM model reflects the MGHinterdisciplinary Professional PracticeModel by which health care providerssurround the patient and family. In theED CM model, the NCM moves intothe second circle to create CM supportand involvement. The NCM, togetherwith the patient and family, ED healthcare team, primary care physician(PCP), and payor, begins a tailored planfor appropriate level of care or servicesrequired. In accordance with the guid-ing principles of the hospital’s patientcare services, “We never lose site of theneeds and expectations of our patientsand their families as we make clinicaldecisions based on the most effectiveuse of internal and external resources.”Figure 1 illustrates the MGH ED CMPractice Model.

Structure/ToolsThe practice model reflects Donabedi-an’s4 model of structure, process, andoutcomes. The ED case managers reportto two team leaders, who in turn reportto the director of case management. Aslisted in Table 1, support structuresinclude such items as job descriptions,standards of practice, organizationalcharts, internal supports (fellow casemanagers, administrative and computersupport, social services, physical thera-pists), and external supports (home care

November/December 2003 TCM 55

FIGURE 1. MGH ED CASE MANAGEMENTPRACTICE MODEL

Structures

Case management administration,advisory board, and support services

Consult services: physical therapy, patient financial advisors, palliative care

Continuing education

Hours of operation

Job descriptions

Organizational chart

Orientation

Physician advisors

Social support services

Standards of care

Standards of practice

Processes

Case finding: rounds, high-risk screens

Consultations: MD, PCP, nurse, patient/family

Documentation

Interactions with patients, health care team and families

Patient assessment: acuity, intensity of service, needed services

Reporting mechanisms

Research

Tools

4-NEXT

CM Web site (intranet)

Communication: computers, beepers,email, VNA referrals

Documentation: medical record, MIDAS

Search tools

TABLE 1. STRUC-TURE, PROCESSES,AND TOOLS FOR EDCASE MANAGEMENTPROGRAM

agencies, shelters, and Boston Health-care for the Homeless physician andnurse supports). The tools necessary toallow MGH to function easier includecomputer access, a computerized docu-mentation system, 4-NEXT (a facility/home care search site), and our own CMWeb site.

ProcessesThe ED case manager identifies high-risk patients by making frequent patientrounds, reviewing current ED patientcensus, and responding to consults fromboth ED physician and nursing staff (inperson or by page). Before seeing eachpatient, a review of the medical recordprovides essential clinical information tobegin formulating a CM plan for level ofcare per managed care appropriatenessprotocol criteria. A review of the medi-cal information data analysis systemprovides information on a patient’shome situation from previous admissionnotes (if the patient or family is unableto provide this information).

The role varies from day to day. TheNCM assesses and reassesses the EDpopulation to continuously identifyappropriate patients and interventionsthat contribute to safe, quality, cost-effective care. The NCM interacts withpatients and families as part of the dis-charge planning process, appropriatelytransferring patients to rehabilitationhospitals, skilled nursing facilities (SNF),or home with services. The departmenthas created a CM Web site that includesa directory of home care agencies, pri-vate pay agencies, and SNFs and reha-

bilitation hospitals by geographic loca-tion. Examples of the ED CM practicemodel include the following cases.

Case Study No. 1An ED RN consulted the NCM toscreen a patient for posthospital needs.An 82-year-old man presented to EDafter a fall 2 days before and now wasunable to transfer out of bed. Thepatient lived with his adult son in a sec-ond floor apartment, was independentwith activities of daily living (ADL)before the fall, and ambulated by usinga cane. The man did not have homenursing services.

After the ED work-up, including labora-tory and radiology examinations, anacute pelvic fracture was diagnosed. Thehealth care team discussed the case anddecided the patient would benefit fromdirect admission to a rehabilitation hos-pital. The NCM met with the patientand son to discuss referrals, and bothmen agreed. Noting the patient’s insur-ance was Medicare and Blue Cross, theNCM had the man screened by a levelone acute rehabilitation hospital, and hewas clinically accepted to the geriatricprogram. The patient and son acceptedthe plan, and the patient was trans-ferred to the rehabilitation hospital byambulance. This action allowed thepatient to begin rehabilitation immedi-ately and avoided an unnecessary acutehospital admission.

Case Study No. 2A pediatrician consulted the NCM toorder a home nebulizer for a 3-month-

old baby diagnosed with an upper res-piratory infection and reactive airwaydisease. The infant presented to the EDin respiratory distress and received twonebulizer treatments; then he was ableto maintain normal oxygen saturationlevels and breathe easier. After inter-viewing both parents, the ED CM hadRespiratory Therapy instruct them onthe disease process and verify that themother could independently use a neb-ulizer. The discharge plan included neb-ulizer treatments every 4 hours for 2days, then only when needed, with afollow-up appointment with the PCPthe next day. The NCM ordered a nebu-lizer from a local vendor (who had acontract with the parents’ insurancecompany), and a machine was deliveredto the family’s home within 1 hour ofdischarge.

Case Study No. 3The ED attending physician consultedthe ED NCM regarding an 80-year-oldwoman who presented after a fallresulted in a right shoulder proximalhumerus fracture. The patient livedalone in a first floor apartment, wasindependent with ADLs before the fall,and received homemaker services 2hours each week through senior ser-vices. Her insurance carriers were Medi-care and Medicaid. The patient asked togo home and did not want to pursuerehabilitation placement. After thewoman demonstrated the ability toambulate and toilet independently, theNCM arranged visiting nurse services toprovide skilled nursing, a home healthaide, and a home safety evaluation. TheNCM arranged transportation homeand ensured a family member would bethere to assist.

Case Study No. 4A patient with a history of a chronicdebilitating genetic disorder presentedto the ED after multiple falls. Thepatient was deconditioned, unable tocommunicate, and totally dependenton family members for all ADLs. Thefamily requested short-term rehabilita-tion to optimize the patient’s conditionand educate them on safe managementat home. The patient was a member ofa health maintenance organization(HMO) with a diagnosis related groupcontract at MGH.

TCM 56 November/December 2003

1998 1999 2000 2001 2002

Acute to acute transfers 18 23 33 37 36

Called to inpatient units 3 117 145 298 262

Case manager consults 121 662 1683 1892 1731

Case manager referrals 62 51 311 569 511

High-tech discharges 15 5 40 49 N/A

Home care referrals 71 147 458 480 502

Initial assessments 300 2067 2321 2284 2135

Rehabilitation transfers 3 13 75 104 79

Short-term SNF transfers 13 18 47 25 71

Transportation issues/arrangements 35 220 472 730 795

TABLE 2. FIVE-YEAR OUTCOME STATISTICS

The patient was admitted under obser-vation status because the HMO requiredformal occupational and physical thera-py evaluation to assess the level of care.The family was willing to continue car-ing for the patient but required trainingon transfers and adaptive equipment.The ED NCM contacted the insurancecase manager the next morning, whoapproved an acute rehabilitation stay.

The ED NCM is in a good position tohelp in the postacute decision-makingprocess by using observation to assesscare levels and collect necessary infor-mation for disposition planning.

These examples illustrate the variety ofactions the ED case managers under-take—a patient transfer to rehabilita-tion, discharge home with high tech-nology and visiting nurse services, andadmission to the hospital. Other con-sults may include setting up dischargehome with intravenous medications orinjections (eg, low molecular weightheparin), helping patients fill dischargeprescriptions, arranging transportation,and consulting on cases requiring ateam effort.

OutcomesOne of our goals is to place the patientat the appropriate level of care. Manypatients who present to the ED do notnecessarily need hospitalization, butthey do not have the necessary supportsto manage at home. The role of the EDNCM, in conjunction with the PCP andhealth care team, is to identify theappropriate level of care to safely opti-mize the patient’s level of functioning.Many patients can be discharged homewith services when the NCM collabo-rates with local visiting nurse organiza-tions and senior services agencies.

Currently, we track the number ofacute-to-acute transfers, patients dis-charged home with services or high techequipment, and rehabilitation andshort-term SNF transfers from the ED.We also collect the number of CM con-sults and referrals (consults are requestsfor CM services; referrals are requeststhe case manager makes to others, suchas physical therapy), initial patient

assessments, and transportation needs,as well as inpatient CM calls after hours(4:00-7:00 PM). Table 2 gives 5-year out-come program statistics. The currentdata have limitations in that numberscan be compounded. For example, a CMconsult can result in sending a patienthome with services or arranging trans-portation. The categories are not limitedto one column, but the data do supportthe growth and demand for the pro-gram. We realize that we need to cap-ture more types of information to docu-ment our overall impact. For example,we can assume that a patient transferreddirectly to a geriatric rehabilitation eval-uation facility will save at least a 3-dayacute hospital stay, which would berequired for a patient to access herMedicare SNF benefit.

This program directly affects hospitalcapacity. As noted, because of the dili-gent work by the case managers in2002, an estimated 150 patients (79 toacute rehabilitation hospitals and 71 toSNFs) were transferred safely from theED to appropriate facilities, resulting inimproved capacity of 150 patients. Addto this the capability of a multidisci-plinary safety assessment for dis-charge, and the ability to send apatient home with maximum servicesleads to safe care and cost-containmentfor the facility.

In the near future, we hope to begintracking complex discharges, quantify-ing potential admissions discharged tohome with services or to rehabilitation,and capturing data on referrals to PCPsand to shelters or respite facilities.

ConclusionCase management at MGH has devel-oped and maintained a successful EDNCM program during the past 8 years.Through support of the CM department,the interdisciplinary team of ED physi-cians and nurses, the PCPs, and hospitalcommunity at large, we strive to improvequality care in a patient-focused, cost-sensitive environment. ❑

References1. Centers for Disease Control National

Center for Health Statistics. Visits tothe emergency department increasenationwide. April, 22, 2002. Availableat: www.cdc.gov/nchs/releases/02news/emergency.htm.

2. Derlet R, Richards JR. Overcrowdingin the nation’s emergency depart-ments: complex causes and disturbingeffects. Ann Emerg Med 2000;35:63-8.

3. Frank I. ED crowding and diversion:strategies and concerns from acrossthe United States. J Emerg Nurs2001;27:559-65.

4. Donabedian A. Explorations in qualityassessment and monitoring: the crite-ria and standards of quality. AnnArbor: Health Administration Press;1982.

Kathleen Todd Walsh, RN, MS, CEN, PeterMoran, RN,C, BSN, MS, CCM, and Chris-tine Greenwood, RN, BSN, CCM, CRRN,are nurse case managers in the emergencydepartment at Massachusetts General Hos-pital in Boston.

AcknowledgmentSpecial thanks to Nancy Sullivan, MBA,and Hilary Levinson RN, BSN, for supportand guidance in writing this manuscript.

Reprint orders: Mosby, Inc., 11830 WestlineIndustrial Dr., St. Louis, MO 63146-3318;phone (314) 579-2838; reprint no. YMCM 87doi: 10.1067/mcm.2003.87

November/December 2003 TCM 57

The role varies from day to day. TheNCM assesses and reassesses the EDpopulation to continuously identify

appropriate patients and interventionsthat contribute to safe, quality,

cost-effective care.