Browsing by Author "Glenn, Adam"

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Open Access
Development of Emergency Department Case Management Case-Finding Tool
(2022-10-05) Gallagher, David; Bentley, Barbara; Barry, Ashley; Moulton, Marcia; Fracola, Amy; Dreibelbis, Lanie; Glenn, Adam; Flanagan, Katie
Society of Hospital Medicine – North Carolina Triangle Chapter Innovation Abstract Development of Emergency Department Case Management Case-Finding Tool David Gallagher1, Barbara Bentley2, Ashley Barry3, Marcia Moulton4, Amy Fracola5, Lanie Dreibelbis6, Adam Glenn6, Katie Flanagan2 1: Duke University Hospital Medicine Programs 2: Duke University Hospital Case Management 3: Duke Health Technology Solutions 4: Duke Regional Hospital Case Management 5: Duke Raleigh Hospital Case Management 6: Duke Health Performance Services Background: Case Managers (CM) are now a standard support component of emergency departments (ED) of large hospitals. They can help with improving quality and decreasing healthcare utilization and costs. ED CM help ensure hospital admissions from EDs are appropriate and if an alternative disposition for the patient exists, then they work towards that goal. ED CMs are important to decrease friction and barriers to the correct care for patients. ED CM responsibilities can include: • Utilization management roles such as evaluating the appropriateness of admission vs. observation vs. discharge • Arranging alternative care destinations such as skilled nursing facility or assisted living • Organizing outpatient resources such as meals, home health care, durable medical equipment • Scheduling medical care follow-up • Referring to support programs and social work for substance abuse, victims of violence, psychiatric care, etc. • Facilitating insurance coverage • Securing housing • Developing high utilizer or individual care plans • Counseling patients and families • Reviewing discharge instructions The majority of ED CM find patients they need to intervene on by using a manual process for case-finding which involves scanning multiple charts or relying on providers guiding them on who to see. The INTERMED tool for case finding is the most common tool in the literature but still represents a manual process that takes significant time. Purpose: As part of our work on reducing readmissions at Duke University Health System we hypothesized that the development of an automated tool for case finding would improve efficiencies for CM, allowing them more time for interventions such as readmission reduction strategies. Therefore, we developed an automated tool that stratifies patients in ED based on variables agreed to by our expert consensus opinion. Description: The tool resides in EPIC EMR ED track board in the CM tab. It is easily seen in CM standard views and workflows. We chose 11 different demographic and utilization variables and weighted them to create an overall CM Priority Score so that patients who should be seen by ED CM would score high. CM Priority scores were color-coded to indicate the need for CM support; red = high need, orange = medium, yellow = low, green = none. CM can hover their cursor over the score to discover the variables driving the score which may help with determining which interventions to apply. Four variables were scored high enough to ensure that CM always saw these patients: ED consult order for CM, potential readmission, complex care or behavioral concern flags, and hospice enrolled. Conclusions: The CM Priority Score tool went live 8/23/22 and we plan on assessing its efficacy and reporting out at a future time. We are holding a rapid improvement event to determine optimal interventions to pursue for patients with high scores in addressing patient needs, readmissions risk, ED utilization, and resource allocation.
Open Access
Development of Emergency Department Case Management Case-Finding Tool
(2023-03-27) Gallagher, David; Bentley, Barbara; Barry, Ashley; Moulton, Marcia; Fraccola, Amy; Santos, Rosimeire; Glenn, Adam; Howard, James; Kamath, Aparna; Flanagan, K
Background: Case Managers (CM) are now a standard presence in emergency departments (ED) of large hospitals, partnering with ED and Hospital Medicine providers to improve care. They are integral in improving hospital throughput and reducing unnecessary hospital admissions and readmissions. Case Managers generally identify high-risk patients using a manual chart review process or by provider request to determine whether hospital admissions are appropriate or if an alternative disposition for the patient exists. This manual case-finding process can be time-intensive and inefficient and was identified as an area of opportunity in rapid improvement events for ED CM at our institution. Purpose: As part of our work on reducing readmissions at an academic medical center our project aim was to develop an automated screening tool for case finding that would improve the ability of CM to identify patients at high risk for return to ED or hospitalization. This improvement in prediction could also be more efficient, allowing CM more time for interventions such as readmission reduction strategies. The Case Management Priority Score (CMPS) screening tool is a clinical innovation developed by interdisciplinary consensus opinion and we report our initial findings. Description: Before CMPS go-live, the standard case-finding methodology used by ED CM to identify high-risk patients was manual. High risk was defined as a return to ED or hospitalization within 7- and 30- day time frames of the index ED visit. Patients thought to be high risk by ED CM using manual case-finding were indicated by documentation in the medical record. The Case Management Priority Score resides in the electronic medical record (See Image 1: Figure) and went live on 9/1/2022. Eleven demographic and utilization variables were identified and weighted to determine an overall CMPS which would guide ED CM to which patients were at high risk for returns or hospitalizations. They can hover their cursor over CMPS to discover the variables impacting the score which may help determine which interventions to apply. Four variables were weighted high enough to ensure that CM always intervened; ED consult order for CM, prior ED or hospital utilization, complex care/behavioral flags, and hospice enrolled. Image 2 (Table) shows baseline characteristics for patients scoring high risk were different than the low risk in all areas except gender. The Table also shows that, compared to the prior manual case-finding methodology (8/2022), CMPS (9/2022) had a higher odds ratio of identifying patients that were at risk for most 7- and 30- day return to ED and hospitalization outcomes. The odds ratio for any 30-day return (ED or hospitalization) for CMPS in 9/2022 was 4.19 (3.17-5.53) vs 1.62 (1.28-2.07) for manual case-finding in 8/2022. Conclusions: In this clinical innovation project, the CMPS screening tool was found to be more predictive in identifying patients at risk for return to ED or hospitalization than manual case finding. If used by CM to identify ED patients to focus on, this may be more accurate than existing manual case-finding techniques, will help ED CM efficiencies, and help reduce returns to ED and hospitalizations. Our future focus for this work includes further analysis of the variables contributing to CMPS to refine the tool for prediction performance and develop strategies to increase its usage among CM.