Rethinking care management at the front end

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As ED visits continue to climb steadily—increasing 21% from 2004 to 2014, according to numbers furnished by the American Hospital Association—it's more important than ever to understand these patients. That understanding should encompass not just medical care but also other potential needs. There's a growing focus on the question of how many of these patients truly require emergent care and how many could be treated in other settings and ways. Earlier this year, Anthem Blue Cross and Blue Shield announced it would no longer cover ED visits for most instances of minor conditions that could safely be treated in less acute facilities.

By re-envisioning and enhancing front-end care management, health systems can take a more comprehensive approach to addressing the dual challenge of assigning patients to the appropriate care setting while also preventing unnecessary visits.

ED care managers can help

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Care managers play increasingly important roles as patient complexities and comorbidities have risen in the inpatient setting. They interpret the broader needs of patients and expedite their access to the right care. We are seeing more organizations in higher volume or at-capacity EDs utilize an ED case manager—typically a licensed practical nurse, registered nurse, and at times a licensed clinical social worker—to improve the timeliness and efficiency of patient placement and throughput.

The role includes partnering with physicians to assist in determining whether a patient should be admitted to inpatient care, placed in observation, or sent to an outpatient setting. The ED care manager performs the initial insurance review and ensures documentation is sufficient to justify medical necessity and prevent denials. (This review is especially important for meeting the two-midnight rule for admission to inpatient versus observation units.) In many situations with a high volume of behavioral and other social issues, the ED care manager can also play a key role by coordinating with social workers to provide psychosocial support.

By relieving other providers of these tasks, a dedicated ED care manager ensures they are completed fully and in a timely manner. When the determination is made that a patient should be discharged from the ED, these care managers champion all aspects of transition and discharge planning, as well as post-discharge follow-up.

Proactively identifying and assessing patients likely to benefit from care management

Increasingly, health systems that are taking on risk and experiencing throughput and capacity issues are working on various means to better manage and coordinate the care for certain patients before they may enter the ED. Strategy development should begin with determining the most leveraged patient population to target: Who is coming to the ED most frequently and why?

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Some of these patients can be identified with predictive modeling. Many health systems start with patients who visit the ED in higher frequencies (e.g., six or more visits per year) with non-emergent care needs. Many of these patients do not have a primary care provider and use the ED as their social/medical safety net.

Although the specific characteristics will vary by institution, these so-called routine patients represent roughly 5 to 8% of ED visitors nationally, but account for upwards of 20% of ED visits and are often costly and difficult to treat.

For these patients, organizations should determine what proportion of ED visits is avoidable or treatable in a lower acuity setting. Some may not have an existing relationship with a primary care physician, for example. It is important to identify the root drivers of their avoidable ED use. Understanding these parameters enables a care manager to design patient plans of care in partnership with a social worker and other ancillary specialists (e.g., a clinical pharmacist) that can meet patient needs through targeted support and interventions, as well as by directing them to appropriate (non-ED) resources and services.

Addressing frequent ED utilizers

One regional medical center identified a subset of the very highest ED utilizers—patients with multiple chronic conditions who came to the ED more than nine times across 12 months—for intensive care management. The dedicated case manager for one of these patients will first assess the patients' clinical and non-clinical risk factors (through chart reviews and a conversation-based assessment), then develop a plan of care for the patient that outlines next steps across clinical, behavioral, and social needs. The case manager will contact and sometimes meet the patient in the ED or in their homes for a holistic understanding of care needs. The case manager also may consult with service providers and attend some patient appointments, monitoring success by tracking the number of ED visits and charges, as well as related inpatient admissions and charges.

Supporting uninsured patients

At another community medical center, care managers focus on providing support to uninsured and underinsured patients visiting the ED for non-urgent reasons. When patients present in the ED, dedicated licensed practical nurses check their insurance and primary care status and assess their needs.

These nurses then refer the identified patients to primary care and then follow up with them by phone. They monitor patient success by tracking the number of ED visits and readmissions as well as the proportion who subsequently receive care at a primary care or other setting instead of the ED.

When truly optimized, front-end care management provides a host of benefits for patients and the organization. Such management can meaningfully improve patient care by coordinating all resources to fully meet patient needs and treat patients in most appropriate setting and expedite throughput for all in the ED both by supporting providers and bringing dedicated effort, as well as reducing volume of unnecessary visits. Finally, optimized front-end care management can reduce readmissions and other costs by redirecting patients to appropriate, lower-acuity care settings.

This article previously appeared on the hfm Blog.

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