Kathleen Todd Walsh, RN, MS, CEN, Peter Moran, RN,C, BSN, MS, CCM, and Christine Greenwood,

RN, BSN, CCM, CRRN

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
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ith the landscape of health care rapidly changing, emergency departments (ED) have been

Facing mounting pressures to deliver safe, effective, quality care despite an unparalleled volume in patients, lack of available treatment space, ominous nursing shortage forecasts, and bed restrictions, EDs struggle to survive.3 An added dilemma presents when ED patient volume exceeds both ED and inpatient bed availability, leading to a backup of patients waiting for an admission bed and those in the waiting room needing evaluation. One solution is to institute case management (CM) to provide options for discharge placement; to work with the health care team to improve safe, quality discharge to home; to reduce expenses in a cost-sensitive managed care environment; and to screen high-risk patients for inpatient versus observation status. This article presents one large teaching hospitals successful ED case management practice model. This patient-centered model focuses on case manager relationships with patients, families, providers, and payors. This

FIGURE 1. MGH ED CASE MANAGEMENT PRACTICE MODEL

TABLE 1. STRUCTURE, PROCESSES, AND TOOLS FOR ED

CASE MANAGEMENT PROGRAM
Structures Case management administration, advisory board, and support services Consult services: physical therapy, patient nancial 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 nding: 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

model suggests a template for other facilities to justify, operationalize, and maintain a successful CM program in the ED. Putting Case Managers in the ED In the past few years, more health care organizations have shown interest in developing ED CM programs. Much of this attention has been spurred with the advent of the ambulatory prospective payment system. This article presents the Massachusetts General Hospital (MGH) ED Case Management Model. This 8-year-old model, consistent with current national CM standards of practice, is being emulated by other institutions nationwide. The MGH program was implemented in 1995 when a nurse case manager (NCM) was placed in the ED to help educate medical and nursing staff about admission criteria, necessity of admission, and alternate placement settings. As the position evolved, two case managers were added and assigned to day and evening shifts to assess incoming patients. The goal was to determine the appropriateness of admission and help the inpatient case managers initiate discharge planning. Over time, the position has evolved and begun focusing on

assessing the needs of high-risk ED discharge patients, developing appropriate and safe discharge plans, and determining the need for alternate settings. Currently, two part-time and one full-time case managers staff the program, and hours of operation are 9:00 AM to 7:30 PM, 7 days a week. ED CM Model The foundation of practice is based in health care relationships. Putting the patient and family at the center of care, the ED CM model reects the MGH interdisciplinary Professional Practice Model by which health care providers surround the patient and family. In the ED CM model, the NCM moves into the second circle to create CM support and involvement. The NCM, together with the patient and family, ED health care team, primary care physician (PCP), and payor, begins a tailored plan for appropriate level of care or services required. In accordance with the guiding principles of the hospitals patient care services, We never lose site of the needs and expectations of our patients and their families as we make clinical decisions based on the most effective use of internal and external resources. Figure 1 illustrates the MGH ED CM Practice Model.

Structure/Tools The practice model reects Donabedians4 model of structure, process, and outcomes. The ED case managers report to two team leaders, who in turn report to the director of case management. As listed in Table 1, support structures include such items as job descriptions, standards of practice, organizational charts, internal supports (fellow case managers, administrative and computer support, social services, physical therapists), and external supports (home care
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TABLE 2. FIVE-YEAR OUTCOME STATISTICS

1998 Acute to acute transfers Called to inpatient units Case manager consults Case manager referrals High-tech discharges Home care referrals Initial assessments Rehabilitation transfers Short-term SNF transfers Transportation issues/arrangements 18 3 121 62 15 71 300 3 13 35 1999 23 117 662 51 5 147 2067 13 18 220 2000 33 145 1683 311 40 458 2321 75 47 472 2001 37 298 1892 569 49 480 2284 104 25 730 2002 36 262 1731 511 N/A 502 2135 79 71 795

agencies, shelters, and Boston Healthcare for the Homeless physician and nurse supports). The tools necessary to allow MGH to function easier include computer access, a computerized documentation system, 4-NEXT (a facility/ home care search site), and our own CM Web site. Processes The ED case manager identies highrisk patients by making frequent patient rounds, reviewing current ED patient census, and responding to consults from both ED physician and nursing staff (in person or by page). Before seeing each patient, a review of the medical record provides essential clinical information to begin formulating a CM plan for level of care per managed care appropriateness protocol criteria. A review of the medical information data analysis system provides information on a patients home situation from previous admission notes (if the patient or family is unable to provide this information). The role varies from day to day. The NCM assesses and reassesses the ED population to continuously identify appropriate patients and interventions that contribute to safe, quality, costeffective care. The NCM interacts with patients and families as part of the discharge planning process, appropriately transferring patients to rehabilitation hospitals, skilled nursing facilities (SNF), or home with services. The department has created a CM Web site that includes a directory of home care agencies, private pay agencies, and SNFs and rehaTCM 56
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bilitation hospitals by geographic location. Examples of the ED CM practice model include the following cases. Case Study No. 1 An ED RN consulted the NCM to screen a patient for posthospital needs. An 82-year-old man presented to ED after a fall 2 days before and now was unable to transfer out of bed. The patient lived with his adult son in a second oor apartment, was independent with activities of daily living (ADL) before the fall, and ambulated by using a cane. The man did not have home nursing services. After the ED work-up, including laboratory and radiology examinations, an acute pelvic fracture was diagnosed. The health care team discussed the case and decided the patient would benet from direct admission to a rehabilitation hospital. The NCM met with the patient and son to discuss referrals, and both men agreed. Noting the patients insurance was Medicare and Blue Cross, the NCM had the man screened by a level one acute rehabilitation hospital, and he was clinically accepted to the geriatric program. The patient and son accepted the plan, and the patient was transferred to the rehabilitation hospital by ambulance. This action allowed the patient to begin rehabilitation immediately and avoided an unnecessary acute hospital admission. Case Study No. 2 A pediatrician consulted the NCM to order a home nebulizer for a 3-month-

old baby diagnosed with an upper respiratory infection and reactive airway disease. The infant presented to the ED in respiratory distress and received two nebulizer treatments; then he was able to maintain normal oxygen saturation levels and breathe easier. After interviewing both parents, the ED CM had Respiratory Therapy instruct them on the disease process and verify that the mother could independently use a nebulizer. The discharge plan included nebulizer treatments every 4 hours for 2 days, then only when needed, with a follow-up appointment with the PCP the next day. The NCM ordered a nebulizer from a local vendor (who had a contract with the parents insurance company), and a machine was delivered to the familys home within 1 hour of discharge. Case Study No. 3 The ED attending physician consulted the ED NCM regarding an 80-year-old woman who presented after a fall resulted in a right shoulder proximal humerus fracture. The patient lived alone in a rst oor apartment, was independent with ADLs before the fall, and received homemaker services 2 hours each week through senior services. Her insurance carriers were Medicare and Medicaid. The patient asked to go home and did not want to pursue rehabilitation placement. After the woman demonstrated the ability to ambulate and toilet independently, the NCM arranged visiting nurse services to provide skilled nursing, a home health aide, and a home safety evaluation. The NCM arranged transportation home and ensured a family member would be there to assist. Case Study No. 4 A patient with a history of a chronic debilitating genetic disorder presented to the ED after multiple falls. The patient was deconditioned, unable to communicate, and totally dependent on family members for all ADLs. The family requested short-term rehabilitation to optimize the patients condition and educate them on safe management at home. The patient was a member of a health maintenance organization (HMO) with a diagnosis related group contract at MGH.

The patient was admitted under observation status because the HMO required formal occupational and physical therapy evaluation to assess the level of care. The family was willing to continue caring for the patient but required training on transfers and adaptive equipment. The ED NCM contacted the insurance case manager the next morning, who approved an acute rehabilitation stay.

Currently, we track the number of acute-to-acute transfers, patients discharged home with services or high tech equipment, and rehabilitation and short-term SNF transfers from the ED. We also collect the number of CM consults and referrals (consults are requests for CM services; referrals are requests the case manager makes to others, such as physical therapy), initial patient

In the near future, we hope to begin tracking complex discharges, quantifying potential admissions discharged to home with services or to rehabilitation, and capturing data on referrals to PCPs and to shelters or respite facilities. Conclusion Case management at MGH has developed and maintained a successful ED NCM program during the past 8 years. Through support of the CM department, the interdisciplinary team of ED physicians and nurses, the PCPs, and hospital community at large, we strive to improve quality care in a patient-focused, costsensitive environment. References 1. Centers for Disease Control National Center for Health Statistics. Visits to the emergency department increase nationwide. April, 22, 2002. Available at: www.cdc.gov/nchs/releases/02news/ emergency.htm. 2. Derlet R, Richards JR. Overcrowding in the nations emergency departments: complex causes and disturbing effects. Ann Emerg Med 2000;35:63-8. 3. Frank I. ED crowding and diversion: strategies and concerns from across the United States. J Emerg Nurs 2001;27:559-65. 4. Donabedian A. Explorations in quality assessment and monitoring: the criteria and standards of quality. Ann Arbor: Health Administration Press; 1982. Kathleen Todd Walsh, RN, MS, CEN, Peter Moran, RN,C, BSN, MS, CCM, and Christine Greenwood, RN, BSN, CCM, CRRN, are nurse case managers in the emergency department at Massachusetts General Hospital in Boston. Acknowledgment Special thanks to Nancy Sullivan, MBA, and Hilary Levinson RN, BSN, for support and guidance in writing this manuscript.
Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 579-2838; reprint no. YMCM 87 doi: 10.1067/mcm.2003.87

The role varies from day to day. The NCM assesses and reassesses the ED population to continuously identify appropriate patients and interventions that contribute to safe, quality, cost-effective care.
The ED NCM is in a good position to help in the postacute decision-making process by using observation to assess care levels and collect necessary information for disposition planning. These examples illustrate the variety of actions the ED case managers undertakea patient transfer to rehabilitation, discharge home with high technology and visiting nurse services, and admission to the hospital. Other consults may include setting up discharge home with intravenous medications or injections (eg, low molecular weight heparin), helping patients ll discharge prescriptions, arranging transportation, and consulting on cases requiring a team effort. Outcomes One of our goals is to place the patient at the appropriate level of care. Many patients who present to the ED do not necessarily need hospitalization, but they do not have the necessary supports to manage at home. The role of the ED NCM, in conjunction with the PCP and health care team, is to identify the appropriate level of care to safely optimize the patients level of functioning. Many patients can be discharged home with services when the NCM collaborates with local visiting nurse organizations and senior services agencies. assessments, and transportation needs, as well as inpatient CM calls after hours (4:00-7:00 PM). Table 2 gives 5-year outcome program statistics. The current data have limitations in that numbers can be compounded. For example, a CM consult can result in sending a patient home with services or arranging transportation. The categories are not limited to one column, but the data do support the growth and demand for the program. We realize that we need to capture more types of information to document our overall impact. For example, we can assume that a patient transferred directly to a geriatric rehabilitation evaluation facility will save at least a 3-day acute hospital stay, which would be required for a patient to access her Medicare SNF benet. This program directly affects hospital capacity. As noted, because of the diligent work by the case managers in 2002, an estimated 150 patients (79 to acute rehabilitation hospitals and 71 to SNFs) were transferred safely from the ED to appropriate facilities, resulting in improved capacity of 150 patients. Add to this the capability of a multidisciplinary safety assessment for discharge, and the ability to send a patient home with maximum services leads to safe care and cost-containment for the facility.

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