1. Effects of Case Management on Frequent
Users of the Emergency Department
Jillian Oliszewicz, B.S, MSN Candidate
Faculty Sponsor: Rose Lach, PhD, RN
DePaul University School of Nursing
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Background
Results
Discussion
Theoretical Framework
Case Management Interventions that were Found to be Effective
Accessible, quality healthcare is one of the most relevant issues at this time. While laws are enacted to ensure access, hospitals are expected to assure quality and efficiency without increasing costs.
One of the many initiatives in place to achieve quality and efficiency of care is to target frequent users of emergency departments (EDs) in order to decrease unnecessary visits. Frequent users of the ED can result in overcrowding, increased cost, compromised quality of care, and reduced efficiency (Grover, Crawford, & Close, 2016; Gayathri & Klein, 2013).
Individualized interventions and planning through case management has been studied as an effective intervention to reduce the number of visits in frequent users.
Case management, as defined by the Case Management Society of America, is “a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy” to meet “an individual’ comprehensive health needs” (2016).
It is hypothesized that applying case management to the identified frequent users of EDs will overall decrease the amount of ED visits, therefore lowering costs, improving patient outcomes, and improving quality of care (Grover et al., 2016).
It was found that telephone, group, and individual based interventions were the most commonly utilized interventions. All studies found a reduction in ED use, and additional benefits included lowered costs and psychosocial improvements, such as increased employment or housing status.
Often, a combination of the interventions was applied and was shown to be effective.
However the most frequently used interventions were individual based. This allowed case managers to implement changes as patient conditions developed.
One study was even able to graduate patients from the case management program once case managers felt the patient could sustain the interventions and access resources without formal guidance. Programs that took the time to individually meet with patients and adjust patient care accordingly were successful.
Orem’s Self-Care Theory
1) theory of self-care
2) theory of self-care deficit
3) theory of nursing system
When there is a deficit in self-care demands and self-care agency, patients seek medical care (figure 1). Case management can individualize plans in order to meet the self-care needs of the patient. It can also be utilized to shape a person’s learned behavior in order to strengthen self-care and minimize deficits that require outside intervention, such as the ED.
Populations
Interventions
Outcomes
Telephone Based (1)
Defined frequent users that were low income, uninsured
-Direct access to nursing manager given Monday-Friday 8AM-5PM
-652 calls took place between patients and the nursing case manager
-ED use decreased
-Hospital charges decreased
-Additional benefits included employment status increasing and homeless population decreasing
Telephone Based (2)
Defined frequent users with exclusion of patients with dementia, psychotic disorders, and terminally ill patients
-Initial interview and support plan developed by nurse
-Regular telephone contact made for monitoring, feedback, and problems
-No difference found in costs
Group Based (1)
-Defined frequent users that were low income, uninsured
-Drop-in group medical appointments (DIGMA) were scheduled twice a week, patients were able to attend as many as desired to address any medical, behavioral, or social issue
-705 patient visits provided, average number of patients per group was 6.5
-ED use decrease
Group Based (2)
-Defined frequent users that gave consent to participate in program
-CM included initial assessment and crisis evaluation with group supportive therapy
-Psychosocial problems were reduced including homelessness, alcohol use, lack of insurance, and financial need
Individual Based (1)
-Defined frequent users with multiple physical illnesses, average age of 44
-Individualize plan of care including coordination of resources and primary care physicians
-Average length of stay with admission decreased
Individual Based (2)
-Defined frequent users
-ED use patterns were identified to determine underlying causes of frequent use
-Individual POC is developed addressing underlying causes
-If a patient presents to the ED the POC is put into action
-Average number of visit continued to decrease each year program was analyzed (at least 6 years)
Individual Based (3)
-Defined frequent users between years old, uninsured, below 200% of the Federal Poverty Level
-Patients are assigned care manager and primary care clinic
-Care managers met with patients monthly to facilitate and coordinate care
-Patients graduated program when care manager felt they were able to address needs without care manager
-No difference in inpatient admissions
Nursing Implications
Nurses interact with patients in the nursing system to address self-care deficits. Case management interventions will help nurses to individually enable self-care practices to allow patients to meet needs without frequent or unnecessary ED use. Nurses will support and empower patients to have care needs met in an appropriate way.
Direction for Future Study
Future studies need to include more multi-year interventions in order to analyze sustainability and differences over time. The few studies that lasted longer than a year did show variations in each year of the study, but further research is needed.
Additionally, special populations need further research in regards to case management. Case management can be difficulty to apply to certain patient populations, such as chronic pain patients, elderly populations, and drug misuser populations. Many of these patient populations were excluded from studies due to that difficulty. Specific interventions need to be developed and tested in these varying populations.
Purpose of Study
Figure 1. Orem’s Self-Care Theory
The purpose of this integrative review of literature is to identify the effects of case management to decrease the number of visits in frequent users of the emergency department.
SELF- CARE
Methods
SELF-CARE AGENCY
SELF-CARE DEMANDS
This study utilized an integrative review method, analyzing recent studies regarding the effects of case management on the number of ED visits in frequent users.
Included studies met the following inclusion criteria:
Frequent users in the emergency department was defined by at least four or more visits in a year.
Interventions were based on applying case management as defined by the Case Management Society of America, including “assessment, planning, facilitation, care coordination, evaluation, and advocacy” (2016).
Follow up data was reported at the conclusion of the intervention test period.
Conclusions
The integrative literature review found that case management is applied effectively to decrease visits in frequent users of the ED. Telephone, group, and individual based interventions were all found to be effective, however some studies noted interventions were not effective with chronic pain patients or prescription drug misusers. In studies that continued for multiple years, the effectiveness of interventions increased in the second or third year.
DEFICIT
NURSING AGENCY