Vituity

The Discharge Dilemma – Keeping Patients Well When They Only Understand a Third of What You Said

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.