Case management outcomes help prove your value to your hospital
Make sure to track avoidable days, overturned denials
If you’re not tracking outcomes that show the value of case management, you’re missing a chance to show your hospital’s administration how much case managers can improve patient care and have a positive impact on the hospital’s bottom line.
"In order to convince hospital administration to allot resources, including budget and people, case managers must be able to show their value to the hospital in a way that the administration can understand," says Teresa Fugate, RN, BBA, CPHQ, CCM, manager at Pershing, Yoakley & Associates, a Knoxville, TN-based health care consulting firm.
"Case management departments should have cost conservation and performance improvement initiatives," Fugate says. "They need to be able to show how these initiatives add value to the hospital in order to continue to receive support from the administration."
Since case management isn’t billable, you have to be able to show administrators the work that case management does and demonstrate to them the outcomes of services that case managers render.
"Case management is not a revenue-generating department, but we are a cost-avoidance department. It’s extremely important for us to measure what case managers do and show the case management department’s value to the organization," adds Mary Raisler, BSN, RN, CPHQ, ACM, system director, care coordination at Washoe Medical Center in Reno, NV.
Case managers must move from being scribes to having objective data that show how their work improves patient care and the bottom line for the hospital, Raisler says.
Anecdotal information is not enough. You need hard data to be able to prove your value to the hospital.
"The best thing that case managers can do to show their value is to make sure they are monitoring things that directly relate to finance," Fugate says. "Unfortunately, case managers don’t always want to talk about the dollar value of their services, but the financial bottom line is how most hospital administrators view value."
When Fugate worked as a case manager at Haywood Regional Medical Center in Clyde, NC, she was able to show enough cost savings to pay for the whole department — salaries, benefits, and operational costs.
Abbe Bendell, RN, CNS, MBA, CCM, vice president, care management, quality and patient safety at Jackson Health System in Miami, took her outcomes data to the health system’s chief financial officer and senior executives and was able to increase the number of case managers within the organization and to convert some existing positions to case management positions.
"It’s very important to be able to prove how much a case manager is worth to the organization," she says. "We’ve always measured indicators that would show our worth, even when case management started in 1992."
Proving the value of case management isn’t easy, especially for people with nursing backgrounds who are not accustomed to dealing with data.
"Case managers tend to monitor more clinical aspects than financial aspects, but in order to be a case manager in today’s health care environment, you have to understand the financial impact of your services," Fugate says.
Understanding the financial aspects of patient care is going to be more important in the future as payments are tied to the efficiency of services provided and documentation of those services, she says.
Now that the Centers for Medicare & Medicaid Services (CMS) has taken the first steps toward pay for performance — and some insurers are moving in that direction as well — case managers must be able to show that the outcomes of their intervention help the hospital meet pay-for-performance goals set by CMS and commercial payers.
"More organizations are asking us to come in and work with case managers who provide interventions for meeting the CMS indicators and preventing delays in services. We’re being asked to help them show the value of their services in improving quality and reimbursement," she adds.
As she travels to hospitals as a consultant, Fugate has observed increasing support for case management from chief financial officers, particularly when case managers are able to produce hard data to show the impact of their services.
"The support from the CFOs is directly related to the fact that the quality indicators are being tied to payment. They are also realizing that case managers are a key in reducing delays in services, making sure the patient moves through the hospital in a timely and efficient manner, and receiving appropriate resources at discharge," she says.
With pay for performance, documentation is crucial, Fugate says.
"Hospitals are including case managers in the programs to improve documentation, because that is the key to payment as well as to reducing delays in service," she says.
For instance, if case managers can document that their interventions resulted in a patient being changed from IV antibiotics to oral antibiotics in a timely fashion, they can show that they not only reduced the patient’s length of stay and cost to the hospital; they also have ensured that the documentation of this positive outcome is in place for pay-for-performance programs.
If you don’t already have case management software that can help you track your outcomes, Fugate suggests finding a good spreadsheet or database program and using it to track interventions and cost savings.
Jackson Health System used spreadsheets and databases to develop its own formats and forms to track case management outcomes.
Teams from case management and the finance office at the hospital worked together with the hospital’s in-house programmers to create a system that interfaces with the hospital’s financial software.
"We had teams of people sitting in a room with paper and sticky notes. We went through many iterations as teams from case management and the financial side worked together to develop the whole system," Bendell says. At Jackson Health System, case managers compile monthly reports for Bendell, who compiles them and generates outcomes data for the department as a whole.
The system allows Bendell to look at length of stay broken out by service line, payer group, individual case manager, and other ways.
The system’s continuum of care abstract includes information on what it takes for patients to meet criteria, discharge planning issues, and core measures. The department’s disease management staff track incidents when they help a patient avoid a hospital admission or an emergency department visit. They monitor pharmacy costs, compliance rates, and whether patients make follow-up appointments with their primary care physicians.
"Our point has been proven. There’s no question about the efficacy of case management. We also use our data to determine appropriate staff ratios and when we need to increase or decrease staff based on patient population," she says.
Use your outcomes information to identify areas where the hospital needs to change policies or improve processes in order to more efficiently move patients through the continuum, Bendell says. Then compare your outcomes over a period of time after the process improvement initiatives, and create graphics that will show your impact at a glance.
"If you are tracking unnecessary hospital days and unnecessary admissions and the impact that case management has on both, you can incorporate some of the effects that discharge planning can have on lengths of stay, such as overcoming barriers in the community by getting a patient bed, or responding to payer issues relating to other levels of care," says Judy Milne, RN, MSN, CPHQ, director of integrated case management and quality improvement at Sarasota (FL) Memorial Hospital.
Monitor your outcomes, including patient outcomes and quality indicators. Add in the financial data, merging financial and clinical outcomes.
"Denials are actual dollars. You can find out how much the hospital loses through denials and show how you make an impact by averting denials," Fugate says.
One way to show your value is to collect avoidable-day data along with case-management interventions that avert avoidable days, and attach a dollar figure to the savings, Fugate says.
Tally the number of avoidable days your case managers averted and multiply them by your hospital’s average cost per day to determine the hard savings the case managers generated, Raisler adds.
If a case manager succeeds in reducing a Medicare patient’s length of stay by one day, the hard savings to the hospital can be calculated by finding the cost per day for that particular DRG.
Case management directors should be collecting these data one patient at a time, entering them into a database, and aggregating them, Fugate adds.
"You can say that avoidable delays are soft dollars, but they do affect the bottom line," she says.
For instance, if you’re backed up in the emergency department and you have to convert patients, this means you need to improve your hospital’s patient throughput. If you reduce the number of days patients are in the hospital, instead of having to divert patients, you have beds available.
"These are not soft-dollar savings when it comes down to having to divert patients or having a bed available so you can care for patients," she says.
If you measure avoidable days, you can determine where you have issues with your process and areas where you need to focus, Raisler says.
For instance, if you discover that there is one physician who always has avoidable days, you then know you need to focus on that particular physician, as well as others in that physician’s peer group.
Raisler compiled data from all the physicians in the peer group before she talked to a particular physician about his avoidable days.
"Physicians respond well to truly objective data if you deliver it in a nonconfrontational manner. They will usually change, especially if you show them how they compare to their peer group," she says.
Readmissions is another important outcome to track because it helps you find glitches in your discharge planning, Raisler adds.
"We looked at unplanned readmissions within 30 days for the same diagnosis and examined whether or not we had an appropriate discharge plan on the first admission," she says.
The department created a standard that all patients who were readmitted within 30 days for the same diagnosis were automatically referred to a social worker for a consultation.
"We wanted to evaluate whether the discharge plan was adequate or whether we needed additional information to ensure that the patient would do well at home," she says.
If youre not tracking outcomes that show the value of case management, youre missing a chance to show your hospitals administration how much case managers can improve patient care and have a positive impact on the hospitals bottom line.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content. TESTING
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