C O L L A B O R A T I V E C A S E M A N A G E M E N T
A View From the Field: Emergency Department Case Managers Support
Innovation that Improves Hospital Revenue
By Ellen Marion, RN, MSN, CNS
Overcrowded EDs, a common challenge in most of the country, lead to delays in patient care, decreased customer satisfaction and lost hospital
revenue. The emergency department (ED) registered nurse case manager at a 300 bed North-Central Florida community hospital improves
existing services and develops new organizational services by increasing patient flow through the ED, developing new innovative treatment
strategies, decreasing length of stay, providing patients with early social assistance, patient education, discharge planning, and assigning correct
billing status to patients upon entering the hospital.
Excessively long wait times by patients needing emergent
care frustrates the customer and can be life threatening.
Patients frequently leave without being seen and ambulances
are sometimes diverted to other facilities farther away. This
same community hospital reported 7,459 patients left without
being seen in 2003. One hour of ambulance diversion has been
calculated by hospital administration to cost approximately
A one-month long pilot program
demonstrated that weekend
availability of cardiac stress
testing in the ED could improve
performance on both service
and financial indicators.
Twelve patients were tested saving
19 hospital days and $17,542.
$10,000.00 of lost hospital revenue1. The ED case manager
has improved patient flow through the ED by avoiding
unnecessary admissions, increasing customer services such
as increasing availability of frequently used diagnostic testing,
and identifying patients with social, educational and discharge
planning needs upon arrival, thus speeding the resolution of
those needs.
While unnecessary admissions happen for a broad
spectrum of reasons, the ED case manager can be instrumental
in reducing those that are a result of no appropriate level of care
for the patient’s needs. Many unnecessary admissions can be
avoided when an ED case manager assesses patients upon
arrival in the ED. The assessment will determine the most
appropriate level of care necessary to meet their medical and/or
psychiatric needs. Alternative levels of care are then discussed
with the ED physician and the plan of care is implemented by
the ED case managers.
3
An ED case manager will provide a level of care perspective
and a specific focus on common patient challenges that can be
resolved in non-inpatient settings. The resulting development
of programs that deliver care in more appropriate settings will
make the difference for many patients, avoiding an unnecessary
inpatient admission. The reduction of those admissions driven
by undue liability caution will require that these new programs
for care gain the confidence of ED physicians and insurance
companies alike.
ONE HOSPITAL’S INITIAL RESULTS
As a result of ED case management, the following results
have contributed to more appropriate care and resource
utilization. To date, this year:
• Nineteen hospital days and over $17,500 saved as a direct
result of new weekend cardiac diagnostic testing during a
one-month pilot program (actual testing was implemented
based on results).
• Six patients were discharged to skilled nursing facilities
(SNFs) to receive IV antibiotics,
• Two patients were admitted directly to a hospice care
facility, and
• Ten patients were discharged home to receive IV antibiotics
by a home health care agency.
• The ED case managers also counsel patients with
psychiatric and/or drug/alcohol problems. An average of
between three and six patients are placed in or referred to
psychiatric facilities per week.
INNOVATIONS IN THE ED
Weekend Diagnostics Avoid Unnecessary Weekend Stays
Avoiding unnecessary days is a key to both a financially
solvent hospital and improved customer service. Weekend
diagnostic testing is essential to prevent unnecessary extended
lengths of stay and the service concerns that result from
backups in the ED due to lack of available beds. A one-month
long pilot program demonstrated that weekend availability of
cardiac stress testing in the ED could improve performance on
both service and financial indicators. Twelve patients were
tested saving 19 hospital days and $17,542. Cardiac stress testing
is now available on weekends.
(continued on page 9)
 C O L L A B O R A T I V E
A View From the Field: Emergency Department Case Managers Support Innovation (continued from page 3)
Early Identification of Social, Education and Discharge Needs
Identifying patients with social, educational and discharge
planning needs upon arrival can also help to alleviate ED
backup, long-term patient outcomes, and return rate. By the
time ED patients have been diagnosed and treated, they are
ready to leave, though they still may benefit from education and
planning for post-discharge needs. However, with the ED RN
focused on the next acute patient, the ED RN case manager can
assist by educating patients with DVTs, diabetes, CHF, COPD
and asthma in an effort to improve long-term patient outcomes
and decrease recidivism in these complex patient populations.
Creative transportation arrangements are also often made for
patients who would otherwise be stranded in the ED. Patients
are assessed and referred to community social services,
medical/dental follow-up care for unfunded patients, domestic
violence safe heavens, and homeless shelters. The ED case
managers often develop innovative solutions to assist patients
to obtain clothing, food, medications and medical/non-medical
equipment. “Social admissions” of elderly patients who can no
longer care for themselves at home and have no acute medical
needs can be reduced by this early case management
intervention in the ED because work can begin immediately to
find a skilled nursing facility placement.
Accuracy of Billing Status
Incorrect billing status assignment can result in denial of
payment by third party payers for hospitalization resulting in
lost revenue for the hospital. Patients who have Medicare
insurance can always be rolled to “inpatient” status but cannot
be rolled back from “inpatient” to “observation” status. The ED
case managers review all patients that are directly admitted to
the hospital and ED patient admissions to determine correct
billing status. Patients can be admitted as “day stay” for
procedures, transfusions, etc.; “observation,” leaving 23 hours to
determine if extended hospitalization is warranted; or
“inpatient.” The InterQual Level of Care Manual by McKesson is
used as a resource to determine the most appropriate level of
care. During periods that the ED case managers are not
available, the patient is admitted in the “observation” status.
When questions arise about validity, treatment ordered, or
billing status requested by a physician, the ED case manager
calls the practitioner for clarification.
Over the past 6 months ED case managers have arranged
for two patients to receive bowel preparation at home by a
home health care agency rather than be admitted to the
hospital the day before surgery. One patient’s billing status for
a colonoscopy was changed from an “inpatient” procedure
to a “day stay” procedure.
Unfortunately, in today’s health care arena, the type of
insurance a patient has can dictate where that patient can
receive treatment. The ED case managers review patients slated
for admission prior to beginning the admission process to
C A S E M A N A G E M E N T
determine if there are “preferred provider” hospital restrictions.
If our hospital is not the patient’s insurance “preferred provider,”
the ED case manager arranges for admission to a “preferred
provider” hospital providing the patient agrees, is stable and can
be transported and the hospital accepts the patient. This service
prevents the patient from paying more out of pocket expenses
for hospitalization.
FUTURE POTENTIAL
Future potential of the ED case management program
may include:
• developing care plans for patient populations who use the
ED as their primary medical care provider in an effort to
decrease their use of ED resources,
• identification of barriers to placing patients in SNFs and
collaborative development of strategies with community
SNFs to assist in emergent placement,
• development of a endovascular management of DVT
protocol (currently underway), and
• the creation of an ED case manager resource manual
for use when a case manager is not available, until
24/7 coverage can be accomplished.
Patient flow and throughput in the ED is of primary
concern for both clinical reasons and patient satisfaction.
The development of initial admission orders to decrease the
time patients spend in the ED waiting for an admitting
physician to write orders could increase ED flow. This could
be implemented by the ED case manager with a telephone call
to the physician to check off the orders he/she wanted to
initiate immediately.
This is a further example of some of the innovative ways that
a hospital can utilize the case managers’ unique combination of
education and training, clinical expertise, and knowledge of
social and health care systems to provide real, measurable
improvements in the medical care of their patients. The ED case
manager role is a valuable, cost-efficient asset. These health care
professionals assist in securing and increasing hospital revenue
by expanding and improving hospital services.
1
Collins, Patti-Ann. (October/November 2004). Care Management,
Volume 10, Number 5 5, Are Emergency Department Registered
Nurse Case managers an Option for Your Hospital? pp. 29-31.
Ellen received a Diploma and Associate of Science degree in
Nursing from Jackson Memorial Hospital School of Nursing and
Miami-Dade Community College in 1980 and a BSN from the
University of Miami in 1989. In 1991 she received a MSN from
the University of Miami. She has worked for over 25 years in
various nursing, education, clinical performance measurement
and Clinical Nurse Specialist roles. Currently, she is a Patient
Care Resource Manager, Clinical Nurse Specialist at Shands
AGH in Gainesville, Fl.