INTRODUCTION

Studies show that health system users demand care transitions resulting from acute and chronic aggravated conditions^(1-2). In general, these individuals experience a combination of complex needs, resulting from coping with multimorbidity, mental health problems, and social vulnerability, which result in a pattern of extreme use of emergency services, with frequent and unnecessary hospitalizations^(3-12).

Despite the growing number of people with complex care and social needs, health care models that focus on illness in health systems still prevail. The complex relationship of social determinants and emotional, psychological, and behavioral factors, which lead to the need to integrate different services to promote continuity of care, is disregarded^(13-14).

Care transition consists of a set of actions to ensure the coordination and continuity of care for patients and promote a safe and timely transfer from one level of attention to another^(2,15). Transitional care approach is related to a comprehensive care plan; communication; safe use of medications; patient and family education to promote self-management; social and community support; participation of the multidisciplinary team to meet the complex care needs of patients; coordination of care; monitoring and follow-up^(16-17).

It is essential to qualify care transition, especially in emergency services, to guarantee and improve patient follow-up after discharge, especially in primary care, and to avoid avoidable future readmissions⁽¹⁸⁾. However, despite the advances in this theoretical conception, both developed and developing countries find, in practice, weaknesses in managing care transition in emergency services^(6,19-22).

The main concern of emergency services is the entry of patients, and gaps related to transitions of care⁽¹⁹⁾. Another important aspect refers to the high demand for care and the high costs of these services since a group of users frequently seeks care in these places on several occasions and for different reasons^(6,19,20,23).

Qualifying care transition requires that managers, health professionals, and researchers are effectively engaged in the ongoing debate to search for resolutive strategies that allow them to deal and adequately manage this complex reality⁽¹⁹⁾.

One of the recommended strategies to improve care transition, case management, has shown promising results in terms of qualifying care, promoting quality of life, reducing unnecessary hospitalizations, and, consequently, health care costs^(24-26).

The ideal case management model is a collaborative process that involves planning, advocating, facilitating, coordinating care, monitoring, and assessing services according to clients' health needs^(27-28). It is made possible through communication between the various members of the multidisciplinary team to meet the health needs of patients and promote effective results concerning the quality of care and health costs^(26,28).

Despite being an internationally consolidated action, in countries like Canada^(20,23,29), United States^(5,29-31), Australia⁽⁸⁾, Switzerland⁽³²⁾, Sweden⁽³³⁾, and England⁽¹²⁾, there is a scarcity of studies that show the importance of case management in care transitions from emergency services to other levels of health care.

In an initial search at MEDLINE via PUBMED to carry out the study, some reviews on emergency services have been identified^(6,20,23,34). The studies highlighted the following benefits attributed to case management: promotion of transitional, continuous, and person-centered care; efficacy and effectiveness when applied to various groups in different configurations; and ability to reduce costs^(25,34). The researchers identified the need to synthesize and deepen the description of the characteristics of these strategies; thus, they mentioned the emergency service guidelines, although it was not the primary objective of the reviews present the strategies used for case management^(6,20,23).

In this context, this scoping review aimed to identify the strategies used for case management in emergency services by synthesizing evidence from studies with different methodological designs.

This study can contribute to support clinical practice and present new possibilities that allow implementing case management to favor timely, safe, and equitable access to people, families, and communities.

OBJECTIVE

To map and synthesize the strategies used for case management in transitional care for patients with complex needs in emergency services.

METHODS

The scoping review developed according to the Joanna Briggs Institute (JBI) methodological assumptions⁽³⁵⁾, in line with Levac, Colquhoun, and O'Brien recommendations⁽³⁶⁾. It followed the PRISMA extension checklist for scoping review (PRISMA-ScR)⁽³⁷⁾. The five methodological were: (1) research question identification; (2) relevant study identification; (3) study selection; (4) result mapping and gathering; and (5) narrative synthesis of the results^(35-36).

The guiding question defined through PCC strategy (P - Population; C - Concept; and C - Context) was: what are the strategies for managing cases in the transitional care of patients with complex needs in emergency services? The investigated context involved serving frequent users of emergency services, with a history of multimorbidity, frequent hospitalizations, impaired mental health, and experiencing situations of social vulnerability^(3,14).

Chart 1 described the eligibility criteria for the studies.

We carried out an initial search at MEDLINE (via PUBMED) and CINAHL (via OVID) databases to analyze the keywords contained in titles and abstracts and controlled descriptors used in the studies identified. Based on this analysis, a chart of controlled and uncontrolled descriptors was built. Such chart included key concepts related to patients with complex needs, care transition, case management, and emergency medical services.

A comprehensive and extensive search strategy was adopted to identify studies published until June 2018, in English, Brazilian Portuguese, and Spanish. The research team defined a search strategy for each database, considering the standardized terminology and the following controlled descriptors from Medical Subject Headings (MeSH): "Critical Care", "Continuity Of Patient Care", "Transitional Care", "Case Management", and "Emergency Medical Services". A specific search strategy was developed for each database, maintaining combinations of descriptors and using Boolean operators (AND and OR).

The searches were implemented in the following databases: Latin American & Caribbean Literature and Health Sciences (LILACS); Medical Literature Analysis and Retrieval System Online (MEDLINE) via the US National Library of Medicine Institute of Health (PUBMED); Cumulative Index to Nursing and Allied Health Literature (CINAHL) via OVID; and EMBASE (Excerpta Medica dataBASE) via OVID. There was also access to the Web of Science Core Collection and Google Scholar.

The following steps were taken: 1. specific search in each database; 2. removal of duplicate articles; 3. selection by title and abstract; 4. assessment by reading the full text, discussing discrepancies and agreeing on the final sample; and 5. review of the articles' reference lists in the final sample. All of these steps were carried out independently, by two reviewers, with training in searching scientific information. For this process, the reference manager software Endnote X 7.4 was used.

To ensure methodological rigor, these reviewers participated in weekly meetings so that they could carefully monitor the search and selection process. It is noteworthy that there was no disagreement among them at any stage.

Mapping and gathering the data included a standardized structure^(35,36) for recording the following information: author(s); year and country of publication; aims; characteristics of the strategies employed; sample; method; results; and main considerations^(35,37).

The narrative synthesis of the results included: (a) numerical synthesis and descriptive abstract; (b) presentation of the characteristics of the case management strategies; (c) synthesis of the results considering the target population and the strategies used for case management in emergency services. The strategies employed were described in terms of the following operational steps^(26,28,38) presented in Chart 2.

RESULTS

After searching the selected databases, assessment and selection of studies were initiated. Of a total of 200 articles initially identified, 161 were excluded for not meeting the pre-established eligibility criteria, and eight were duplicated citations, leaving 31 publications for a full reading. In this step, 31 articles have been included, based on assessing the reference lists. However, after reading full-text of the 62 articles, 39 were excluded for not explicitly addressing case management in emergency services so that the final sample analyzed corresponded to 23 articles. The results are described in the flowchart shown in Figure 1.

Figure 1 Flowchart, according to PRISMA, for selection and inclusion of studies in the scoping review⁽³⁷⁾ 

Most were published between 2014 and 2018 and conducted in the United States (14 articles) and Canada (4 articles). The methodological approaches used were experimental^{(11,32-33,39)}, quasi-experimental^{(7,9,12,40-41)}, observational^{(4-5,8,30,42)} studies, systematic reviews without meta-analysis^(6,20,29), thematic analysis reviews⁽²³⁾, and other modalities (experience reports and reflection articles)^(31,43-46) (Chart 3).

The studies showed that the most frequent users are patients with complex needs related to vulnerability (people with psychiatric problems, substance abuse, especially alcohol and drugs, chronic clinical conditions (cardiovascular, neurological and pulmonary) and, to psychosocial stressors (social isolation, lack of health insurance, homeless people, poverty, lack of community resources and housing).

Moreover, it was highlighted in some studies that the frequent, disproportionate and inappropriate use of emergency services increases the demand, costs, and damages the adequate quality and safety of care in these units^{(4-9,11-12,20,23,29-30,32-33,40,42)}.

The researchers presented different configurations for the team responsible for case management in emergency services. Models centered on the role of nurses^{(4-5,21,30,32-33,39-40,42-43,44,46)} and contemporary models were identified, in an expanded and multidisciplinary perspective, composed of physicians, nutritionists, nurses, occupational therapists, physiotherapists, and social workers^(7-9,12,45).

The case managers actions in emergency services were performing the screening, and assessing the psychosocial needs of patients and families^{(33,39,41,44,46)}; evaluate the discharged patients' needs and who are at high risk for readmission⁽⁴⁶⁾; identifying the motivation of individuals to seek assistance in emergency departments^(4,30) and, the barriers to receive care in an outpatient setting^(30,43).

Other roles of case managers include facilitating decision-making and coordination of clinical care^(8,23); promoting diversified and safe discharge⁽⁸⁾, helping teams to develop individualized care plans^{(4,8,23,33,39,41,45-46)}. They are responsible for promoting educational actions for self-management of care^(8,23,33,41); coordinating care follow-up by informing patients about care level options, and thereby contributing to reducing the misuse of emergency services due to organizational care limitations^(8,30,44).

Regarding the strategies used for case management, a central concern was identified with care optimization to prevent or reduce the need for new access to emergency departments by frequent users. In this context, case managers play an essential role in implementing the continuum of hospital and community care services, which includes clinical assessment, coordination, and communication with other service providers⁽³²⁾.

In the studies analyzed, strategies focused on coordinating and integrating patients to return to the community prevailed, by monitoring the results of both the care team and the case manager^{(4,7,32,40,44)}. Activities identified as useful were primarily a comprehensive and extensive clinical assessment; technological improvement, such as electronic health records, to establish effective communication between the different levels of health care; and notification of case managers about potential patients to be admitted to the program^(7,42).

These activities improve the experience of patient care in emergency services; facilitate the decision-making of the multidisciplinary team for safe transfer of responsibility for care to other levels of health care and the family context; optimize communication among health professionals, patients, and family members; favor the definition of the most appropriate level of care to reduce the length of stay and avoid frequent use of emergency services; reduce costs of care; and, consequently, promote safety and quality^(39,41,45). The main strategies implemented for case management are synthesized in Chart 4.

The strategies adopted for managing the cases included: screening and assessment of patients^{(5,8,11-12,30,32-33,39-40)}; development of an individualized care plan^{(4-5,7-8,12,32-33,39-42)}; care coordination through a multidisciplinary performance^{(4-5,7-8,12,32)}; support for the transition process through patient education actions^{(22,32,40-41)}; communication^{(7,30,32,40-41)}; monitoring, follow-up, and assessment^(33,39,41) for periodic verification of their needs and progress.

Case management begins with screening and assessment in emergency departments when case managers review the medical records and electronic records to identify frequent service users at high risk of relapse and with complex care needs^(32-33). Then, telephone or letter contact is made with patients eligible to receive case management, inviting them to participate in the program^{(4,11,32-33,39)}. If accepted, they attend a one-to-one interview with the case manager, to collect information about their clinical and psychosocial needs as well as to identify the reason that led them to seek emergency care and the barriers identified by them for primary care assistance^{(4,11-12,30,32-33,39-41)}. This information enables identifying the appropriate level of care for patients to ensure timely access and continuity of care^(12,30).

Emphasis on developing individualized care plans was placed in most of the studies analyzed^{(5-6,8,11-12,30,32-33,39)}. Care plans aim to coordinate the services needed for patients for both hospitalization and outpatient treatment; prevent inappropriate admissions; improve discharge plans; reduce costs; ensure patient satisfaction and refer to appropriate locations⁽⁴⁰⁾.

There is an incentive to involve and actively participate in developing a care plan, as they are factors that favor decision-making and contribute to identifying appropriate solutions to problems^(8,30). Thus, it is possible to allow patient improvement concerning the care they need, and the means of achieving it^(4,11,30)) are evidenced.

Another significant aspect concerns implementing electronic records systems in emergency departments, since they allow to identify frequent service users and create an individualized care plan. In this way, the multidisciplinary team will have access to the information of these patients and will be able to adapt the plan, if necessary^{(4-5,12,39,41-42)}.

The study conducted by Pillow et al.⁽⁴²⁾ showed that implementing a program for electronic screening through alert icons visualized in the electronic registration system of emergency departments helps identify frequent users with complex care needs. In such cases, the team must communicate the fact to the case manager so that the case management process can be triggered. A professional case manager then places a notice on a board in the emergency department to alert the medical and nursing staff about the treatment of patients enrolled in the program⁽⁴⁾.

Patient education is a necessary approach throughout the case management process. Case managers act as advisors and educators^(23,40), both concerning care self-management and on the services available at different levels^(6,30,32). Moreover, they provide patient guidance to properly use the health system ^{(20,32,41,46)}, providing care options, and helping them make the most appropriate choices^(32,44) .

Communication among professionals, provision of resources in the community, access to primary care physicians, quality of care and reduction of costs, visits, and inappropriate admissions to emergency departments are expected and reported results in most interventions^(5,21,41).

In emergency services, there were, among frequent users, people in situations of vulnerability due to mental health problems and alcohol and drug abuse. For this population, emergency service case managers maintain direct communication with primary care professionals; and together, they participate in planning strategies to ensure the follow-up, assessment, and periodic reassessment of patients' needs and their progress in primary care^(7-8,11,30).

One of these strategies involves assertive community outreach treatment, performed by professionals with training in social assistance, nursing, and psychiatry. The aim is to provide intensive support and guided by their needs so that patients return to the community and do not need new hospitalizations or seek emergency services unnecessarily^(7-8,11,30).

Multidisciplinary teams must act in an interconnected manner under the leadership of case managers, whose central role is to promote coordination between clinical and social service providers, emergency services, outpatient care, and home care^{(4-6,8,11-12,20,23,29,30,32,40-42,44,46)}.

Another key action involves patient monitoring and follow-up. The studies that addressed this strategy highlighted case management through telephone contact and home visits, facilitating communication with other health professionals through case managers, and monitoring after the implementation of the managed care plan^(33,39). These studies indicated that this follow-up improves service to users, contributes to reducing the number of visits to emergency departments, days, and costs of hospitalizations and, consequently, favors health system use.

In this sense, studies have shown that case management is a model of care coordination that involves patients and allows them to be referred to the level most appropriate to their clinical and psychosocial condition. It occurs through the assessment of available support services and identification of barriers found for timely access, to meet the real needs of patients and promote safe discharge^{(6,8,20,23,33,40,44)} .

DISCUSSION

This scoping review mapped the scientific evidence related to case management strategies in the transition of care for adults and older people with complex needs in emergency services over the past 21 years. Current case management models involve the conception of people-centered care, with the perspective of guaranteeing people effective continuity of health care. It requires a multidisciplinary health assessment system formed by a set of logical steps and a process of interaction between health care networks to guarantee an appropriate transition of patient care throughout the health system^(3,27).

Most of the mapped and synthesized studies showed that the case management strategies implemented in an emergency, for users with complex care needs, have been effective in reducing service use. Furthermore, according to studies, these actions guarantee coordination and continuity of care for other settings, especially for primary care^{(5,12,30,33,39,41-42)}.

This model has been used to integrate services around patients' individual needs through the coordination of care^{(7,30,32,40-41)}. It can be implemented through using information technologies, such as electronic health records systems, to identify patients who need to be enrolled in this type of program^(5,30,42).

In emergency services, this process has the central objective of promoting the ideal transition of patients to guarantee continuity of care and better adapt the use of these services^(7,11,32). There is evidence that this model contributes to patients obtaining the necessary care in the health system^{(4,7,12,27,40)}.

Case management responds to the complex needs of patients and aims to promote self-management of care and improve the integration of this population with health services⁽²³⁾. Case management has taken on a central role in terms of coordinating high complexity care in emergency services, especially for frequent users who have complex clinical and psychosocial needs^{(8-9,12,20,23,29,32,40-41)}. In some cases, such strategies also include the relatives of these patients^(9,23,45).

It is perceived that case management, when effectively implemented, promotes the connection of patients with primary care, which is fundamental to avoid fragmentation of care. However, for this to be genuinely contemplated, it is necessary to have a case manager who works within the emergency department and establishes communication with the outpatient network about the essential care for patients, ensuring continuity and avoiding recurrences in the service^{(4-6,9,20,29,23,32-33)}.

Case management is an intervention that favors the monitoring of these people through screening, care, and follow-up planning for continuous monitoring of patients' progress and patterns of demand for health care, quality of life, and feedback regarding patients' responses to implemented care plans^(5,33,39) .

Screening emerges as a central element and involves an approach with embracement, identification, and accurate assessment of users and their families, not only to solve their immediate problem, but mainly, to promote adequate regulation to other levels of care. Moreover, this step is vital to ensure continuity of information for other health professionals and, above all, to promote safe and useful user navigation in the health system^{(5,12,23,32,42)}. Screening patients includes the assessment of their clinical and psychosocial needs, intending to identify early risks of admission and readmission in emergency services. These people are monitored until stability or until they can seek care in the appropriate setting⁽³⁹⁾.

However, for this plan to be successfully implemented, one of the essential strategies for case management intervention in emergency services, in addition to the presence of a professional case manager and the involvement of patients in creating their care plan, consists of developing and implementing an electronic registration system^{(23,30,32-33,39,42))} . This strategy allows establishing timely communication and promotes the support and participation of patients, families, the multidisciplinary team, and healthcare team in the construction, adherence, and adequacy of the plan, whenever necessary.

As a strategy for linking users, the studies highlighted the importance of effective communication between the case manager and other professionals involved in the development process as well as the review of individualized care plans in primary care. These factors promoted patient engagement and partnership between primary care professionals and those of the services for which, generally, these users will be referred to follow this plan^{(4-5,7-9,11-12,40)}.

Some studies have highlighted the role of nurses and social workers in leading case management implementation in emergency services^{(20,23,44-45)}. The partnership with social work was emphasized as well as the importance of psychosocial interventions and planning of complex transitions from acute care to outpatient care.

The researchers also highlighted the nurses 'competence to carry out an expanded clinical assessment of patients' needs, their knowledge about the management of organizational resources, and interpersonal, leadership and communication skills to work with other team members. Nurses were recognized as a link between the different levels of health care and as responsible for promoting continuity of care, reducing fragmentation, and favoring more positive results^{(20,23,44-45)}.

Case management in emergency services requires skills to serve clients comprehensively and holistically concerning clinical, psychosocial, behavioral, and spiritual needs; encourage self-care, and increase the involvement of individuals and caregivers in decision-making^(10,28).

Another essential action provided by case management is the possibility of patient follow-up and monitoring. To that end, strategies such as telephone contact can be adopted to clarify the patients' doubts about the care plan. Case managers carry out home visits to assess responses to the care plan and, if necessary, promote adjustments^(39,41).

The researchers also highlighted the comprehensive care actions related to health counseling and education with a focus on self-management and guidelines for dealing with psychosocial issues. Many highlighted the integrated performance of the multidisciplinary team and the central role of nursing and social work in this process^{(4-9,11-12,20,23,29-30,32-33,40,42)}.

To briefly summarise, most of the case management strategies were multimodal and included strategies to promote health education⁽³⁰⁾; screening focusing on the patients' biopsychosocial needs^(33,39); development of an individualized care plan^(12,30,33); social service support⁽³³⁾; and coordination of care within the health service system^{(8,12,32,39-42)} .

Such strategies are centrally focused on minimizing fragmentation of care within the health system and help patients navigate this system, as they favor access to appropriate resources available in the different care spaces and facilitate user engagement and development⁽²⁸⁾. The central objective is to guarantee the best results using standard guidelines, working together with the interdisciplinary team, improving safety and customer satisfaction, favoring adherence to the care plan for costumers, including adherence to medication^(27,31-32).

It is a process that aims to ensure the right care, in the right place and at the right time, avoiding fragmented care^(27-28), which facilitates promoting effective care and quality results for patients. For this strategy to be effective, collaboration, cooperation, and mutual effort between different health care providers are essential. Besides, the coordination aims to organize care so that it is accessible whenever necessary. Another crucial aspect is communication, as case managers must work with several people to ensure that patients receive care⁽²⁷⁾.

To sum up, employing case management strategies in transitional care in emergency services contributes to planning discharge and transferring responsibility from emergency services to other levels of health care. Home context prevents inappropriate admissions, reduces service usage and costs, and improves patient and team satisfaction. Besides, case managers become a link between patients and community resources. They advise patients on the importance of follow-up with primary care professionals; improve clinical management across the continuum of care; and promote the effective defense of patients so that they have ensured continuity of care⁽⁴⁴⁾.

FINAL CONSIDERATIONS

This scoping review presented a global perspective on the 23 studies that addressed the strategies used for case management in the transitional care of patients with complex needs in emergency services.

In conclusion, it was identified that screening with risk assessment; individualized and progressive care planning; and coordination of care through establishing effective communication among multidisciplinary teams in different care contexts were fundamental to the favorable outcomes of the strategies implemented. Furthermore, they favor identifying possible paths for emergency service qualification. Strategies were also highlighted to promote support for the transition process through health education actions and the establishment of communication between the different levels of health care and monitoring, follow-up and assessment of patients to verify the progress of their health care needs.

Employing case management responded to the complex needs of vulnerable costumer through a structured approach that promoted support for self-management and favored integration of patients with health services. In addition, developing an individualized care plan to meet the clinical and social needs of patients is capable of promoting adequate use of emergency resources and services.

In general, the results reaffirm the need for emergency services to have a professional case manager and specific multidisciplinary team to coordinate the care of frequent users; and to identify the motivations of frequent search and the barriers of access to other levels of health care.

Using case management strategies favors coordination and continuity of care in the health service network; and contributes to patients being properly informed about the services available to meet their needs and the appropriate time to use emergency services. Such aspects are necessary to build innovative and interactive ways to promote the ideal transitional care of patients with complex care needs, which transcend the limits of traditional care in emergency services.