Is the integration of urgent, emergent, inpatient and
care of patients with
acute medical conditions.
By True McMahan, MD
It goes without saying that most patients arrive to the ED in a flurry of chaos, stumbling over their words, embarrassed about the circumstances that brought them there, and about the lack of planning that led to the emergency in the first place. The majority of the time, their “emergency” is stabilized and they are sent home (as Mark Spiro noted in his post, not all ED visits are emergencies). Yet, the stress of the visit will linger, the trauma or drama will cloud their understanding of their condition and the discharge instructions.
Emergency Medicine research studies show the patients’ retention of discharge and medication instructions from EDs ranges about 25-30% at best. These same patients are asked to take that 30% of retained information and try to engage in follow up care, fill the prescriptions and understand our verbal and written return precautions. But do they? The same studies show that patients rarely make follow up appointments, only fill prescriptions half of the times, and some even return within a few hours or days to go through it all again.
While in some HMO structures the case management departments are alerted through the health plans that an ED visit has occurred and follow up is needed, this only happens for a small portion of most ED populations. Most are uninsured or underinsured and even the PPO and EPO patients have no case managers to check on them after their ED visit. The upshot is that sometimes the patients bounce back to our ED, and unfortunately, sometimes they bounce to another facility. In order to establish a fluid Acute Care Continuum, we should really consider having our own ED Case managers who can assist in navigating our patients’ post-ED needs.
Emergency Medical Case Management is a collaborative process that facilitates recommended treatment plans to assure the appropriate medical care is provided to the ED patients. It refers to the planning and coordination of health care services appropriate to achieve the goal of medical intervention. Case Managers can help coordinate medical resources, communicate healthcare needs for patients and their families, as well as monitor an individual patient’s progress and promote cost-effective care. They are knowledgeable about the community’s resources and they can take on the accountability for the care, when often the patients’ emotional response of the ED encounter can cloud their own resourcefulness. In short, case Managers in the ED can help provide a needed dimension for follow up care.
The cost of the case managers can be considered preventative control costs. A case manager’s salary in Orange County, California is approximately $68,000 annually, but the savings are clear. The follow up care provided by case managers helps prevent bounce backs by correcting the misinformed and helping the recovering patients navigate the very confusing health care environment. Prevention of poor follow up can save potentially millions of dollars in health care costs. A single missed or poor follow up can result in an indemnity case with millions of lost dollars, not to mention our patients’ possible morbidity and mortality. As we truly embrace the responsibility of the Acute Care Continuum we should consider investing in case managers.
While it may be challenging for every ED to have their own case manager, it is possible that a case manager could be within reach through creative approaches. For example, currently in larger volume EDs a case manager is assigned specifically to the ED by the hospital. However, for most medium and small volume EDs, such as my hospital, there is usually no such resource. But perhaps the cost of case managers could be shared regionally similar to an insurance plan to offset the cost of illness.
ED case management would offset the cost of poor follow up, assist in the direction of post-acute care, and provide many resources for our ED patients. This would demonstrate our commitment to the entire need of the patients after they leave our EDs.
Dr. McMahan is the QI Director and Medical Director-elect at Garden Grove Medical Center. She earned her Medical Degree at the Baylor College of Medicine and completed her Residency at UCLA Medical Center. She is a CEP America Partner and a CPAC member.
There is, I feel, an alternate paradigm of perspective, which in mo way diminishes the strength of the article, nor i think should be construed as a competing perspective (as I have seen done in articles, without mentioning names i can point toward a salient example in which a piece was written arguing tat the strongest barrier to patients accessing their medical and health records/information was a lack of interest, being informed properly of how they can and why they should, being the main reason for them not doing so, in a challenge to the assumed paramount prevailing argument that hospitals, and health providers deliberate construction of barriers and obstacles in an effort to control patient information, records and their content being the main reason, when the only point that ultimately invalidated both arguments was the conclusion, which was dependent on the qualifying claim of one reason being the strongest over others, and one another, which given the practical impossibility of making a definite calculation to verify which one was the biggest, rendered the truth value of both conclusions as undetermined and invalidated both otherwise valid arguments.) And so, likewise to the article I had read in regard to patients accessing their health information b(or lack there of), i feel that there is potentially a concurrent argument which should be recognized concurrent with this article, the underpinnings of which can be (i feel) much more directly recognized by an interpolation of media forms, than suggested in a long-form article : http://www.youtube.com/watch?v=8TB0BF4jtkM&feature=plcp
Patient perspective... Very poignant article. I am in the middle of a medical "situation" that began with the ER and a hospital stay. One and half years later, retaining and acting (properly) upon all of the information I've been given has proven to be VERY difficult. Further complicated by the fact that I have multiple doctors/specialists involved, each with their own scope of work, and (my) issues they are trying to resolve. Given I've spent a lot of insurance money (seven figures, so far), a case worker tasked to help me resolve these things would very likely save money, ultimately...
I strongly agree with both Dr. McMahan and Bonnie Carl, and particularly agree with Dr. McMahon's sentence, "Prevention of poor follow up can save potentially millions of dollars in health care costs." This was shown startlingly in the now-famous article, "The Hot Spotters" by Dr. Atul Gawande, in this sentence about the success of aggressive follow-up support for the highest ER utilizers: "Their hospital bills averaged $1.2 million per month before and just over half a million after—a fifty-six-per-cent reduction." This also supports Bonnie's point that knowledge of community resources is its own skill set, and a valuable one.
Case management in the emergency department is cost effective on a variety of levels. In addition to working with patients to facilitate them following discharge instructions by scheduling follow-up appointments and filling prescriptions, case managers take care of a myriad of issues that would otherwise take the time and attention of ED nurses and providers. Since most case managers are, themselves, nurses they understand the burden faced by overstretched ED staff to find appropriate care for patients who either do not have insurance or do not have a relationship with a physician. Case managers, who frequently have their fingers on the pulse of community resources, become a repository of information and local contacts to facilitate ongoing care. This is expecially helpful with regard to placements of patients requiring skilled nursing or psychiatric care. When a case manager is in place, the ED nurses and physicians can focus on caring for the patients coming through the door while someone else is working on appropriate disposition of the patients they have already seen. Since the days of the "social admission" are a thing of the past, hospitals save money by avoiding unncessary admissions and keeping ED staff doing what they do best. The patient, the hospital, the ED staff ....... it's a win ... win ....win....!
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