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An Academic Medical Center Model
Discharge Screening: Emergency Department Case Managers
Help Improve Compliance with Discharge Instructions
by Barb Quick, RN
Perhaps there are as many ways to utilize case managers in an Emergency Department (ED) as there are Emergency Departments. Hospital
size, location, population served, acute care case management model in place and historic practice patterns drive the best design of the
model. At Barnes Jewish Hospital (BJH), the case management function in the ED has evolved since it was first established in 1995. One
of the most valuable services the case managers currently deliver is discharge screening, which is beginning to dramatically impact the
way emergency resources are used by the BJH community.
Barnes Jewish Hospital is an academic medical
center, affiliated with the medical school at
Washington University in St. Louis. The ED has 62
beds and sees about 75,000 annual visits. About 25%
of patients arrive by city ambulance and are very
often victims of crime or violence. BJH has the only
Level 1, American College of Surgeons (ACS) verified
trauma center in the region. For this reason, many
patients arrive by air transport – either from the
scene of an accident or once stabilized at another
hospital in the region.
In 1995, case managers deployed in the ED had
utilization management (UM) as their primary
focus. One of the reasons that case management
was introduced in the ED was the implementation
of managed care for certain Medicaid populations.
Notification for permission to treat in the ED was a
requirement for these populations. Other UM-
related activities of the case managers were assuring
medically appropriate admissions and identifying
stable patients who were “out-of-network” or
A Community Hospital Model
Case Managers Add
Great Value to
Emergency Departments
by Karen Riley, RN
Many case management departments
have goals that include decreasing the
hospital’s length-of-stay (LOS), decreasing
readmission rates and decreasing the
number of inpatient days denied payment
by payers. Lakeland Regional Health
System’s case management department
focused on these three goals in August
of 2002. An analysis of the continuum
of care led to a decision to staff the
emergency department (ED) of Lakeland
Hospital-St. Joseph, the flagship hospital
in the system, with case managers from
9 am to 9 pm, seven days a week.
“non-contract” so that they had the opportunity
to transfer to a hospital where they would receive
maximum insurance coverage according to their
health plan.
NEW LAWS ALLOW A ROLE CHANGE
For two years, these were useful and
cost-effective roles for the case managers. In 1997,
however, the Missouri legislature made it illegal for
health insurance companies to require payer
notification for treatment in the ED. A companion
law also passed, which defined “emergency” in
layman’s terms such that an insurance company
cannot determine retrospectively whether a true
emergency existed. These laws kept the hospital
from being caught between EMTALA and
insurance company requirements. They also
allowed the case management role to be recast.
With the time-consuming effort to notify and
obtain certifications to treat no longer necessary,
case management attention turned to a critical
Lakeland Hospital-St. Joseph is a 254-bed THE ED CASE COORDINATOR’S JOB
medical center with a full range of acute care Preadmission/ED Care Coordinator is
services. The ED sees over 61,000 visits per year the title used by the 2.4 FTEs that work in
and 50% of acute care patients are admitted
through the emergency room. A focused case
the ED. The specific job duties for this all-RN
staff include:
management effort in the ED clearly showed
• Review of admissions in “real time” to avoid
the potential to reduce both the readmission
inappropriate admissions; and location of
rate and the number of inpatient denials
alternative care settings for those who do not
resulting from an inappropriate status for an
meet the criteria for an inpatient or
acute care admission.
observation admission.
As the sole hospital in the St.Joseph/
Benton Harbor community, Lakeland Hospital • Pre-certification of those who will be admitted.
is sometimes viewed as the solution by patients
• Review of surgical schedules several
who frequent their doctors’ offices with
days in advance to ensure that patients
inappropriate requests for treatment or by
are pre-certified for the appropriate
families who turn to a hospital to solve a care-
status (outpatient, observation or
giving problem. “Social admissions” occur
inpatient) according to established criteria
when a caregiver cannot or will not provide
and payer guidelines.
care for a patient for a temporary period or is
abandoning the role of caregiver for some • Assessment of discharge planning needs of
reason. These admissions may result in patient and initiation of a discharge plan on
payment denials by payers because the patients admission to meet desired clinical goals;
do not meet the standard of medical necessity plan includes next steps in the care
for the acute care setting. continuum and identification and resolution
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need of many ED patients: locating appropriate follow-up care in an most often their homes. Repeat visits by these patients for their non-
appropriate setting. emergency follow-up care or, because the patient was unable to comply
with discharge instructions, is frequent. A system is in place at BJH to see
THE “NEW” CASE MANAGEMENT MODEL
that these patients receive the support necessary to facilitate compliance
Case Management Staffing
with discharge instructions.
Social workers are dedicated 24/7 to the ED and are a part of the case
An RN case manager reviews discharge instructions for patients who are
management department. The primary role of the social workers is a
seen for a complaint or diagnosis that falls into the “urgent care” or non-
specialized one: assisting and counseling families and loved ones of the
emergency categories. All patients seen in the ED who do not have a
critically ill patients and working with homeless patients. Grief counseling
primary care provider to see for follow-up care are counseled by the case
and helping patients and families through crises dominates their activity
manager. When follow-up care is required for these patients, it is the case
around the clock. Because these specialized skills are in such demand, social
manager’s first step to provide the patient with information and education
workers are not given the more traditional case management duties.
regarding options for follow-up care, such as a federally funded clinic or
RN case managers are staffed “34/7” in the ED. This means that between
other appropriate clinic setting.
noon and 10 p.m. there are two RN case managers on duty to cover peak
BJH has resources available to assist the patient in complying with a
periods of patient activity. Relieved of the pre-certification and notification
follow-up visit. In some cases this means faxing the clinical information
duties as a result of the 1997 legislation, an RN case manager’s time is now
directly to the clinic or arranging for patient transport to the appointment.
allocated about 70% to screening discharges, 5% to screening transfers out (a
Several of the local federally-funded clinics allow the BJH case managers
rare occurrence for a tertiary center), 15% to screening admissions and
to send patients to the clinics without appointments to ensure timely
observation stays and 10% to screening mental health admissions (which is
follow-up when necessary.
still required). The decrease in the amount of time required for screening
The next step is to review discharge instructions to determine needs for
admissions is due to the level of physician screening prior to admission. The
support in addition to primary care follow-up. In addition to using the ED
ED is staffed by full time emergency medicine physicians who have been
for follow-up care, patients will make unnecessary repeat visits to the ED
well educated regarding admission appropriateness.
when needs such as affordable (or free) medications, durable medical
Discharge Screening equipment, home care, and transportation to appointments are not met.
Assuring the appropriate level of care is central to the case management The case managers ensure that DME and home care vendors have the
mission. In the emergency room setting, freed up from a primary focus on information they need to bill the patient’s insurance. In addition, when
the flow of patients into the acute care setting, case managers focus on the insurance is unavailable, ED case managers are fortunate to have access to
flow of patients who are discharged from the ED to a non-acute setting, funds at the BJH Foundation that can provide for unmet needs.
(continued on page 7)

of any medication issues that impact
discharge. Collaboration with an
interdisciplinary team and communication
with inpatient care and management staff to
assure continuity of care.
• Collaboration with and education of physicians
and ER staff about appropriate clinical
documentation to accurately reflect severity of
patient’s illness; maintaining knowledge of
appropriate utilization of services and levels of
care based on clinical situations and payer
guidelines to optimize reimbursement and
compliance with regulations.
• Service as primary resource to family and
patient for education regarding the plan of
care and expected outcomes.
• Assessment of financial needs, covered
benefits and alternate level of care options,
so that appropriate applications for assistance
or referrals are made and to maintain the
financial well-being of the patient/family
and the hospital.
THE FIRST YEAR – TALLYING THE IMPACT
Care coordinators have been in the
Lakeland Hospital ED for more than one year.
All ED care coordinators keep a worksheet of
their activities and accomplishments during
each shift. Specific outcomes are tracked in this
manner, including admissions avoided, home
care referrals and follow-up appointments
made for patients.
Between March and December 2003,
106 admissions were avoided because of
interventions and solutions arranged by
care coordinators. This resulted not only in a
cost savings for the hospital but also in the
avoidance of “social,” inappropriate and
possibly fraudulent admissions. Additionally,
the care management department as a
whole has contributed to a decrease in the
readmissions rate and the inpatient denial
rate. These performance gains could not have
been made at Lakeland without focused
intervention in the ED.
On a more subjective note, the staff and
physicians in the ED highly value and respect
the care coordinators as critical “go to” team
members. As a resource for complex problem-
solving, the care coordinators have freed up
more time for staff nurses to spend on patient
care. The staff members working in the
positions — who transferred from the obstetrics,
pediatrics and medical oncology units —
report they enjoy the quick pace, patient
turnaround and wide variety of patients that
the ED setting provides.
Karen Riley is a registered nurse. She received her
diploma from the Blodgett Memorial Medical
Center School of Nursing in Grand Rapids, MI,
and her BS in Health Studies from Western
Michigan University in Kalamazoo, MI. Currently
the manager of care management at Lakeland
Regional Health System, she has 20 years of
experience in obstetrics, neonatal and pediatric
nursing, and more than five years experience in
staff educator roles.