Strategies for case management in transitional care in emergency services: scoping review

Braz, Priscilla Gonçalves de Castro Gomes; Vila, Vanessa da Silva Carvalho; Neves, Heliny Carneiro Cunha

doi:10.1590/0034-7167-2019-0506

Brasil

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REVIEW • Rev. bras. enferm. 73 (Suppl 5) • 2020 • https://doi.org/10.1590/0034-7167-2019-0506 linkcopy

Strategies for case management in transitional care in emergency services: scoping review

Estratégia para el manejo de casos em la atención de transición em servicios de emergência: scoping review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective: to map and synthesize the strategies implemented for case management in transitional care for patients with complex needs in emergency services.

Method: a scoping review conducted under the Joanna Briggs Institute guidance. Twenty-three studies were analyzed, with different methodological designs, on the strategies used in case management involving adult and elderly populations in emergency services.

Results: the main strategies employed were patient risk stratification screening/identification, care management plan, coordination of care through multidisciplinary activities, support for the transition process, continuous patient monitoring, and follow-up.

Final considerations: these strategies used structured approaches to care in emergency services to promote support for self-management and effective transitional care for people with complex needs, ensuring comprehensiveness, coordination, and continuity of care.

Descriptors: Case Management; Patient-Centered Care; Transitional Care; Review; Emergency Medical Services

Inclusion criteria

Exclusion criteria

Participants - adults (18 years old and over) and older people (over 60 years old), regardless of gender, with complex needs.
Concept - strategies for case management in transitional care.
Context - emergency services
Type of study - quantitative studies (clinical trials; quasi-experimental studies; prospective and retrospective observational studies; analytical case-control and cross-sectional studies); qualitative studies (descriptive, phenomenological, ethnographic, action research and theory based on data); systematic reviews (with or without meta-analysis) and meta-syntheses; gray literature (documents and books published by organizations focused on case management).

• Not presenting the descriptive steps of the strategies for managing cases in transitional care.

• Editorials, research protocols, comments, theses, and dissertations.

Step	Aim
1^st step Risk stratification screening/identification	- To identify (risk stratification) the health situation (clinical and psychosocial aspects) of patients, as well as the services required to meet health needs and that, may affect the progress of care; assessment of readmission risk; and resources in the community and potential care partners⁽²⁶^,²⁸^,³⁸⁾.
2^nd step Assessment of patients' needs	- To assess and identify patients' and families' needs: 1. Health history and medications used; 2. Data on family and caregiver; 3. To verify if they have a family physician or primary care physician; 4. Analysis of hospital clinical records, including past and current emergency services, auxiliary health teams, employers; 5. Medication in use; 6. Other administrative documents and home care services; 7. To identify needs for interventions that should be incorporated into a care plan; 8. To determine the resources needed to address the issues raised⁽²⁶^,²⁸^,³⁸⁾.
3^rd step Development of a care management plan	- To develop an individualized care plan based on clinical and psychosocial needs, in collaboration with the entire team involved in case management, to ensure the safe transfer of care in the continuum of care ⁽²⁶^,²⁸^,³⁸⁾.
4^th step Plan implementation with care coordination	- To implement the care plan covering all interventions necessary to ensure and maintain the continuity of care for individuals at all levels of health care⁽²⁶^,²⁸^,³⁸⁾.
5^th step Care plan assessment and follow-up	- To review, follow up, assess, and monitor the patients' responses to the implemented care plan as well as monitoring and reassessing the patients' health conditions⁽²⁶^,²⁸⁾. - To gather information and share it among professionals; assess the Effectiveness, need for adjustments in the care plan and its effects on the patients' health status and recommend new interventions; verify if patients and family are satisfied with care and services after discharge⁽²⁶^,²⁸^,³⁸⁾.
6^th step Support in the transition process	- To facilitate the progress of care by advancing the care plan, aiming to achieve the desired results and integrating the health care teamwork to achieve the defined goals; to identify, communicate, and resolve barriers that thwart the progress of care; and optimize outcomes across the continuum of care⁽³⁸⁾.
7^th step Post-transition communication	- To communicate and share information among patients, multidisciplinary teams, primary care providers, and support systems⁽²⁶^,³⁸⁾. - To verify the care plan implementation: patient comfort; medication adherence; availability of post-transition services; requesting feedback on the experience and satisfaction of patients with services provided; verification of problems and search for resolution; and transfer of information acquired from service providers⁽²⁸^,³⁸⁾.
8^th step Periodic reassessment	- To examine adherence and verify the patients' responses to the care plan, the need for adjustments; clarify doubts of patients, families, or caregivers; and verify patient satisfaction⁽²⁶^,³⁸⁾. - To confirm access to services after discharge; determine the need for interventions to prevent readmissions from the emergency department; ensure follow-up in primary care, and complete the case management process based on patient and family conditions⁽²⁸^,³⁸⁾.

Author(s), Title	Year/ Country	Journal/Book	Method	Strategy^* * Strategy employed: 1. Screening/identification and assessment; 2. Individualized care plan; 3. Support and communication in transitional care; 4. Coordination of care through a multidisciplinary team; 5. Monitoring and follow-up of patients.
Hudon C, Chouinard M-C, Lambert M, Diadiou F, Bouliane D, Beaudin J.⁽²³⁾ Key factors of case management interventions for frequent users of healthcare services: a thematic analysis review.	2017 Canada	British Medical Journal Open.	Thematic analysis review	1-5
Grover CA, Crawford E, Close RJ.⁽⁵⁾ The efficacy of case management on emergency department frequent users: an eight-year observational study.	2016 United States	The Journal of Emergency Medicine	Observational study	1-5
Edgren G, Anderson J, Dolk A, Torgerson J, Nyberg S, Skau T, et al.⁽³³⁾ A case management intervention targeted to reduce healthcare consumption for frequent Emergency Department visitors: results from an adaptive randomized trial.	2016 Sweden	European Journal of Emergency Medicine	Randomized controlled clinical trial	1-3,5
Bodenmann P, Velonaki V-S, Griffin JL, Baggio S, Iglesias K, Moschetti K, et al.⁽³²⁾ Case management may reduce emergency department frequent use in a universal health coverage system: a randomized controlled trial.	2017 Switzerland	Journal of General Internal Medicine	Randomized controlled clinical trial	1-5
Soril LJ, Leggett LE, Lorenzetti DL, Noseworthy TW, Clement FM.⁽²⁹⁾ Reducing frequent visits to the emergency department: a systematic review of interventions.	2015 Canada	PloS one	Systematic review	1,2
McCarty RL, Zarn J, Fenn R, Collins RD.⁽³⁰⁾ Frequent ED utilizers: A case management program to address patient needs.	2015 United States	Nursing management	Before-and-after quasi-experimental study	1-4
Walsh K, Z.⁽³¹⁾ Emergency Department Case Management: the compendium of best practices	2014 United States	Emergency Department Case Management: the compendium of best practices	-----	2
Kumar GS, Klein R.⁽⁶⁾ Effectiveness of case management strategies in reducing emergency department visits in frequent user patient populations: a systematic review.	2013 United States	The Journal of Emergency Medicine	Systematic review	2-5
Reinius P, Johansson M, Fjellner A, Werr J, Öhlén G, Edgren G.⁽³⁹⁾ A telephone-based case-management intervention reduces healthcare utilization for frequent emergency department visitors.	2013 Sweden	European Journal of Emergency Medicine	Randomized controlled clinical trial	1-3,5
Pillow MT, Doctor S, Brown S, Carter K, Mulliken R.⁽⁴²⁾ An emergency department-initiated, web-based, multidisciplinary approach to decreasing emergency department visits by the top frequent visitors using patient care plans.	2013 United States	The Journal of Emergency Medicine	Retrospective cohort study	1,2,4
Rinke ML, Dietrich E, Kodeck T, Westcoat K.⁽⁴¹⁾ Operation care: a pilot case management intervention for frequent emergency medical system users.	2012 United States	The American Journal of Emergency Medicine	Before-and-after quasi-experimental study	2-5
Althaus F, Paroz S, Hugli O, Ghali WA, Daeppen J-B, Peytremann-Bridevaux I, et al.⁽²⁰⁾ Effectiveness of interventions targeting frequent users of emergency departments: a systematic review.	2011 Canada	Annals of Emergency of Medicine	Systematic review	2,4
Grover CA, Close RJ, Villarreal K, Goldman LM.⁽⁴⁾ Emergency department frequent user: pilot study of intensive case management to reduce visits and computed tomography.	2010 United States	The Western Journal of Emergency Medicine	Retrospective observational study	1-5
Skinner J, Carter L, Haxton C.⁽¹²⁾ Case management of patients who frequently present to a Scottish emergency department.	2009 United Kingdom	Emergency Medicine Journal	Prospective observational study	1,2,4
Shumway M, Boccellari A, O'Brien K, Okin RL.⁽¹¹⁾ Cost-effectiveness of clinical case management for ED frequent users: results of a randomized trial.	2008 United States	The American Journal of Emergency Medicine	Randomized controlled clinical trial	1,2,5
Phillips GA, Brophy DS, Weiland TJ, Chenhall AJ, Dent AW.⁽⁸⁾ The effect of multidisciplinary case management on selected outcomes for frequent attenders at an emergency department.	2006 Australia	The Medical Journal of Australia	Retrospective cohort study	1,2,4
Lee K-H, Davenport L.⁽⁴⁰⁾ Can case management interventions reduce the number of emergency department visits by frequent users?	2006 United States	The Health Care Manager	Before-and-after study	1-5
Walsh KT, Moran P, Greenwood C.⁽⁴⁵⁾ A successful emergency department case management practice model.	2003 United States	Case Manager	-	1,2,5
Okin RL, Boccellari A, Azocar F, Shumway M, O'Brien K, Gelb A, et al.⁽⁷⁾ The effects of clinical case management on hospital service use among ED frequent users.	2000 United States	The American Journal of Emergency Medicine	Prospective study	1,2,4,5
Bristow DP, Herrick CA.⁽⁴⁴⁾ Emergency department case management: the dyad team of nurse case manager and social worker improve discharge planning and patient and staff satisfaction while decreasing inappropriate admissions and costs: a literature review.	2002 United States	Lippincotts Case Management	Literature review	1,4,5
Pope D, Fernandes CM, Bouthillette F, Etherington J.⁽⁹⁾ Frequent users of the emergency department: a program to improve care and reduce visits.	2000 Canada	Canadian Medical Association Journal	Before-and-after study	1,2,4,5
Walsh KM.⁽⁴⁶⁾ ED case managers: One large teaching hospital's experience.	1999 United States	Journal of Emergency Nursing	Experience report	1,3,4,5
Brewer BB, Jackson L.⁽⁴³⁾ A case management model for the emergency department.	1997	Journal of Emergency Nursing	Experience report	1-5

STRATEGY	SYNTHESIS OF STRATEGIES IMPLEMENTED
Risk stratification screening/identification	- Use of electronic records systems from the emergency department to insert the individual care plan⁽⁴^-⁵^,⁸^,¹¹^-¹²^,³⁰^,32-33^,³⁹^,⁴²⁾ and information systems for screening frequent users(5,12,21,30,39); recruiting patients with complex care needs⁽²³⁾. - Systematic review of medical records for systematic and early identification of high-risk patients eligible for case management⁽⁴^-⁵^,⁷^,¹¹^,³⁰^,32-33^,³⁹^-⁴⁰^,⁴⁶⁾. - Assessment of patients one-to-one after telephone contact⁽⁴^,¹¹^,³²^-³³^,³⁹⁾. - Sending a letter to the primary care physician to invite patients to participate in the case management process, provided they are frequent users of emergency services⁽⁴^,³⁰^,³⁹⁾. - Interview for complete initial assessment of patients' clinical and psychosocial needs⁽⁴^,⁷^,⁹^,11-12^,²⁹^-³⁰^,³²^-³³^,³⁹^-⁴⁶⁾. - Dialogue between the case manager and the emergency department physician to understand the case and discuss the expected treatment and appropriate admission level⁽⁴⁵⁾. - Identification of the motivation of individuals to seek assistance in emergency departments and the barriers they encounter for assistance in the community context; identification of which care path can be provided⁽⁵^,¹²^,²⁰^,²³^,⁴⁰^,⁴⁶⁾; and investigation of factors related to the overuse of health services⁽²³⁾. - Identification of health care services that can be successfully and effectively provided⁽¹²^,³⁰⁾; assessment of the levels of care and collection of information necessary to prepare the planning⁽⁴³^,⁴⁵⁾.
Care management plan	- Individualized care plan developed by the case manager together with the multidisciplinary team to coordinate the services for patients ⁽⁴^-⁹^,¹²^,²³^,³⁰^,32-33^,³⁹^-⁴²⁾; understanding of patients' clinical needs; providing recommendations for the care plan; avoiding inappropriate hospitalizations and reducing the number of visits to emergency departments⁽²⁰^,²³^,²⁹^,⁴³⁾. - It should involve best practices related to planning the transition of patients with complex psychosocial needs by the social worker; simple transfer planning performed by emergency department case managers, and discharge planning after patient admission to the emergency department performed by a home case manager and social worker⁽³¹⁾. - Directed to the clinical and social needs of patients and families⁽⁴^,11-12^,³⁰^,32-33^,³⁹^-⁴¹⁾. - Focus on establishing therapeutic goals and objectives that promote self-management of health and counseling in search of solutions to psychosocial problems and definition of the best follow-up of care in other levels of health care⁽⁸^,³⁰⁾. - Engagement of the entire care team in creating a comprehensive care plan, with interventions and continuous reassessments of patients' problems⁽⁴^-⁵^,⁷^,²³^,³²^-³³^,³⁹^-⁴²⁾.
Care management plan	- Invitation and active involvement of patients in the review of their case (self-management); participation in creating their individualized care plan and in the search for solutions to their problems⁽⁴^,⁹^,¹¹^,³⁰^,³³⁾; and dialogue with the team and family about the need for referrals, care plans and goals to be achieved⁽⁴⁵⁾. - Conducting complex transition planning to coordinate clinical care in emergency departments⁽⁹^,⁴⁶⁾; discharge plan⁽⁴¹⁾; creating a comprehensive after discharge care plan, including coordination of care in insurance, transportation, housing and meeting clinical, and psychosocial needs⁽⁴^,6-7^,¹¹^,²⁰^,²³^,29-30^,³²^,⁴³^,⁴⁵⁾. - Promotion of actions involving health education, empowerment in decision-making, and encouraging self-management of care and patient participation in developing their care plan⁽²⁰^,²³^,⁴⁵⁾. - The care plan should be updated, revised, and shared considering the needs of patients and future risk of hospital admission, according to stratification⁽¹²^,²³^,⁴¹⁾. - High risk (care plan reviewed every three months, intensive case management and advocacy); - Medium risk (care plan revised in 6 months and telephone contact to monitor and implement the care plan and address emerging problems); - Low risk (care plan revised in 12 months).
Post-transition support and communication	- Patient education and guidance on the proper use of the health system and clinical and social services available in the community⁽⁶^,²³^,³⁰^,32-33^,39-41^,⁴⁶⁾; helping patients find solutions to their problems⁽⁵^,⁴³⁾; - Patient guidance regarding self-management of care, offering care options, and helping you to make appropriate choices⁽³²^-³³⁾; patient counseling on risky behaviors (e.g., substance abuse) and clinical service use⁽²³^,³⁰^,³²^,⁴³⁾. - Communication with the entire team and with different providers and levels of care⁽³²^,⁴¹^,⁴³⁾; liaison with other community agencies(7,22,40); communication with other levels of care(33,39,41); informing the primary health care physician about scheduled appointments and the need for follow-up(32).
Care coordination	The multidisciplinary work includes physicians, nurses, social workers⁽⁴^-⁵^,⁷^-⁹^,¹²^,³²^,⁴⁰^-⁴⁴⁾, primary care professionals, nutritionist, occupational therapist, physiotherapist, among others⁽⁸^,⁴⁶⁾; Collaborative work with the multidisciplinary team to support case management⁽²³^,⁴⁰⁾ and develop recommendations regarding the use of this service and treatments that should be provided in this context⁽⁴⁾; - Multidisciplinary case conference to discuss cases⁽⁵^-⁶^,⁹^,¹²^,²⁰^,²³^,³⁰^,⁴¹^-⁴²⁾;
Follow-up, assessment, and periodic reassessment of patients' needs and progress	- Proactive and close contact between patients and care providers through phone calls or visits ⁽³³^,³⁹⁾; telephone access to a case manager to answer questions⁽³³^,³⁹^,⁴¹⁾; - Telephone follow-up scheduled based on the risks of hospital admission⁽¹¹^,²³^,³²^-³³^,³⁹⁾; and home visits or telephone contact to verify care plan adherence and adjustment⁽⁶^,²³^,⁴¹^,⁴³^,⁴⁵⁾ and reassess it if patients return for care, to check if they are receiving coordinated services appropriate measures to decrease the use of emergency services⁽²³⁾; - Providing an email or phone for patients to contact if there are problems at discharge. It must be ensured that calls will be returned by the case manager on the same day⁽²³^,⁴³⁾; - Regular meetings with a case manager and visits by a case manager to assess patients' responses to the individualized care plan and, if necessary, review it⁽⁴^,²³^,³⁹^,⁴¹⁾; - Home care⁽⁸^,³⁰⁾; continuous monitoring electronically monitored by nurses with follow-up actions and feedback on the patient's progress⁽⁵^,³³^,³⁹⁾; definition of patterns of demand for health care and quality of life; and verification of the need for new admission of patients⁽⁴³⁾; - Implementation of assertive community treatment that involves a proactive and confident approach, emphasizing health promotion and prevention and acute treatment. It consists of home visits to discuss the case, follow^-up consultations, screening and identifying patients, especially frequent users of emergency services with impaired mental health⁽⁷^,⁹^,¹¹^,²⁰^,³⁰⁾; - Patient referral to another care setting, in order to ensure continuity of care in the short and long term⁽⁴^,⁷^,¹¹^,²⁰^,³²^,⁴³^-⁴⁵⁾; reference for primary health care, community services⁽⁴^,⁶^,²⁰^,²³^,²⁹^-³⁰^,³²^,⁴⁰^,⁴³^-⁴⁴^,⁴⁶⁾ and services to deal with substance abuse⁽¹¹^,²⁹⁾; referral for social counseling service, crisis intervention, assertive program in the community, support therapy and assistance to obtain housing and connection with care provider⁽⁵^-⁷^,⁹^,¹¹^-¹²^,²⁰^,²³^,²⁹^,³²^-³³^,⁴⁰^-⁴¹^,⁴³⁾; - Creation of a case management website that includes community agencies, private agencies, and rehabilitation hospitals⁽⁴⁵⁾; information sharing: electronic registration system between care providers; access to the individualized care plan through the system by the entire team involved in the case management process⁽²⁹⁾.

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[TFN2] ^*
Strategy employed: 1. Screening/identification and assessment; 2. Individualized care plan; 3. Support and communication in transitional care; 4. Coordination of care through a multidisciplinary team; 5. Monitoring and follow-up of patients.