Case Managers Can Play Crucial Role in Emergency Department

By Kelly Bilodeau

More than 139 million patients come through the doors of U.S. hospital emergency departments (ED) every year, and many move into inpatient hospital beds. “About 70% of patient hospital admissions go through the ED,” said Marie Stinebuck, MBA, MSN, ACM, COO at Phoenix Medical Management Inc. 

ED case managers can serve as gatekeepers for this high-traffic entry point, ensuring accurate status determinations, preventing unnecessary readmissions, and helping to keep as many inpatient beds open as possible.

The right services for the right patient

Not everyone who arrives at the ED needs to be there or meets the medical criteria required for inpatient admission. Some individuals come in because the patient and/or the family need custodial, not medical support, Stinebuck said. An ED case manager can offer patients more appropriate alternatives. Depending on the patient’s needs, this may include referrals for community services, medical support, or placement resources if home care is not a viable option.

The ED case manager can also intercept potentially avoidable readmissions. Patients discharged from the hospital sometimes reappear in the ED within 30 days for problems that don’t warrant another inpatient admission. “Most electronic medical records have a readmission flag,” Stinebuck said. So, when these patients arrive in the ED, it triggers a notification to the case manager, who can quickly interview and assess the patient. Often, patients come back because of logistical problems that are manageable without a hospital stay—they couldn’t fill a prescription or missed an appointment with the primary care doctor. In other cases, a readmission is unavoidable, but the case manager can decrease or prevent future return visits by creating complex care plans for high-risk patients, including those with substance use disorders or behavioral health challenges, Stinebuck said.

While managing high-risk patient populations is a crucial part of an ED case manager’s role, they must also verify that patients are assigned correctly as inpatients or outpatients with observation services. UR reviews at admission can help ensure the patient receives the right level of care.

Establishing an ED case management program

To begin an ED case management program, assess your existing processes to determine when case management services are most needed, Stinebuck said. Look at the number of ED admits, identify peak hours in the ED, and monitor for high-utilizing patients and inpatient readmissions. Peak ED hours don’t always match 9 a.m. to 5 p.m. schedules. A case management shift could be most beneficial from 10 a.m. to 6:30 p.m., 4:30 p.m. to midnight, or 10 a.m. to 10 p.m. Depending on your community and patient population, you may or may not need an overnight case manager.

“If you want to set up a new program, start during your peak hours, knowing that you're going to get the biggest bang for your buck,” Stinebuck said. Ideally, you should have one case manager for every 30 patients.

In a busy ED that sees 60 to 70 patients at a time, you may need to assign more than one case manager with overlapping shifts to meet demand.

Understanding your patient demographics can also help you determine who is best for this ED case management role, a nurse or a social worker. “If you’re a trauma facility with a high homeless population or drug seekers, social workers have training to deal with this social complexity and psychosocial components and are a better fit in the role than a nurse.” Stinebuck said.

An ED case manager must work closely with ED providers to be effective. “Staff members in the ED really need to have a good understanding of what that case manager does and the support they can offer,” Stinebuck said. Ultimately, a well-structured program can help hospitals manage the large and unpredictable flow of patients entering through one of its busiest departments and help keep hospital beds open for the people who need them the most.

Case Management Corner is your go-to source for insightful discussions on relevant topics in case management. Through an engaging interview-style format, our team members share their expertise, experiences, and best practices to keep you informed and empowered. Whether you're looking for industry updates, practical strategies, or real-world perspectives, we bring you valuable conversations designed to enhance your knowledge and support your professional growth. Stay tuned for expert insights straight from the field! Kelly Bilodeau has been a longtime writer for HCPro’s Case Management Monthly.