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As more hospitals plan staff cuts due to the poor economy and tighter restrictions on reimbursement by the Centers for Medicare & Medicaid Services (CMS) and commercial insurers, case managers are challenged with determining how to demonstrate how their department positively affects the hospital's bottom line and to justify hiring new staff or avoiding staff cuts.
Case management directors frequently say they can't get approval to hire additional staff because it's difficult to show how case management brings value to the hospital as it is not a revenue-generating department, points out Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY.
"We are part of an interdisciplinary team that presents a package of care delivery to patients. The hospital may not bill directly for case management services, but we do bring value to the organization," Cesta says.
Case managers need to determine the right data to track and present those in a meaningful way to demonstrate the effectiveness of their program and to justify having enough staff to effectively complete the tasks they are expected to handle, she says.
"Few case management departments consider themselves fully and appropriately staffed," she adds.
Case managers today are challenged to coordinate care for sicker patients with fewer resources and are pressured to move them through the continuum quickly and develop a creative discharge plan that maximizes the available resources and prevents readmissions, says Kathy Rickard, RN, BSN, MBA, associate director, clinical resource management and social work at the Hospital of the University of Pennsylvania in Philadelphia.
"Case management is an increasingly complex and difficult job. We have more requirements from CMS and insurers, which add to the case manager's daily workload, and we have to be able to demonstrate all that we do," she adds.
For instance, the requirement that patients receive the Important Message from Medicare informing them of their right to appeal their discharge takes a lot of the case manager's time.
"This is not a simple task. It involves discussion with the patient and family members to make sure they understand it. It's an additional part of everyone's responsibilities that has to be absorbed into our daily routine. It is challenging to do what was previously required when new government regulations add to the load," Rickard says.
Regulatory issues and CMs
Regulatory issues, such as the Important Message from Medicare, often are the responsibility of case managers and affect the hospital's compliance with Medicare's Conditions of Participation (CoPs), Cesta adds.
"Case managers can demonstrate the impact on the hospital's compliance with the Conditions of Participation. At the very least, case management directors can track how their work involves compliance issues to make the point that the case management department is not a closed department and that it brings value to the organization by ensuring compliance," she says.
Rickard's department tracks the number of patient contacts each case manager makes, the number of placements to various levels of care, the number of referrals for home health, and a variety of other performance measures and submits those to a benchmarking organization that compares the performance of the Hospital of the University of Pennsylvania to other academic medical centers.
The department provides the benchmarking information to the hospital administration to justify staffing levels when there is a need to fill an already budgeted position or to request additional FTEs when a new unit opens.
"The number of discharge planning assessments and the numbers of resources we set up for patients after discharge are keys in justifying the number of staff we have. The benchmarking data show that our staffing levels are on par with other hospitals that treat equally complex patients. Finance looks very carefully at the benchmarking data," Rickard says.
Process metrics were the first measures used in case management, and they still are useful to demonstrate productivity, Cesta points out.
Measure outcomes, not just processes
"Tabulating the number of patients a case manager or social worker touches, how many reviews they conduct, how many discharge plans they create — all are process metrics that indicate the volume of work. Productivity measures have been the foundation of how we identified the work of case managers; but today, we need to move beyond them from measuring a process to a measuring a true outcome," she says.
In order to begin demonstrating the benefits of what they do, case management departments should have a set of annual and short-term goals that mesh with the goals of their organization, Cesta says.
Look at the objectives of your department and what you are trying to achieve. Then determine the impact you are having on the organization and come up with ways to demonstrate the outcomes in a manner that other departments and disciplines can understand, she suggests.
When you create your case management outcomes report, don't use a lot of jargon that is specific to case management because others may not understand what you are saying, Cesta cautions.
Don't be redundant and report data that already are being reported by other departments.
"People are inundated with data. If you report the same data as another department, consider referring to the other department's data in your report," Cesta suggests.
As you put together a set of metrics to include in your outcomes report, write a definition for each metric and include a definition page in your report.
Make sure the data you report have meaning for your department as well as the organization as a whole, she adds.
Make sure that the metrics you report on are measurable and are under your control.
Some outcomes are affected by multiple departments and disciplines and are only partly under the control of case management, Cesta points out.
In your report, differentiate between the various types of case management outcomes and don't assume ownership of outcomes that are not entirely under your control, she suggests.
Make sure that your report points out that situations beyond the case manager's control can affect your outcomes in these areas, she says.
LOS comes first
"Length of stay is the No. 1 barometer in case management outcomes, but it is one of those metrics that is affected by virtually every department and discipline in the hospital. Typically, case management owns length of stay, but it is in fact affected by other departments," she says.
For instance, the clinical status of the patient and the case manager's ability to place the patient in another level of care are among the variables that affect length of stay.
Cost per day and cost per case are other outcomes that case managers affect through coordination of care but that ultimately fall back on the physician's order and the ability of the case manager to move the patient through the continuum, she says.
Although case management is responsible for denials reporting, other areas of the hospital have an impact on denials, she adds.
In reporting case management outcomes, find a balance between the clinical and financial outcomes, Cesta suggests.
"We do ourselves a disservice if we don't report both clinical and financial outcomes. The financial impact should be a clinical quality impact as well," she says.
In the hospital setting, the bottom line is not just financial but also includes the quality of care that patients receive, she points out.
For instance, delays in service can have an impact on quality of care as well as reimbursement because if a patient is not receiving services in a timely fashion, he or she is not receiving an appropriate level of care, Cesta says.
Inappropriate admissions affect quality because patients are not receiving appropriate care in the appropriate setting. They affect patient flow because nonacute patients are in an acute care bed, delaying acute patients from occupying the bed and creating a backlog in the emergency department.
"Patient satisfaction is also a quality outcome metric. Look at your hospital's patient satisfaction questions and make sure there are questions that are relevant to case management," Cesta suggests.
Track cost avoidance
Tracking cost avoidance is very important, Cesta points out.
"This is something that case managers do on a daily basis but don't give themselves credit for," she adds.
For instance, if your emergency department case managers avoid two "social admissions" each month at an average daily cost of $800 a day and a length of stay of two days, that saves $38,400 a year.
Another example is showing that case management facilitated the discharge of two patients per month, decreasing the length of stay by 2.5 days at a savings of $48,000 a year.
"If you keep track of these, you can demonstrate quite a bit of revenue your department saves the hospital," Cesta adds.
Track your hospital's case mix index if your department is responsible for clinical documentation improvement and if you affect the reduction of inappropriate admissions, she says.
"Case mix index is another indicator that we watch to monitor the financial health of the hospital. So much work of case managers affects the case mix index, including stopping inappropriate admissions, ensuring that the documentation fully represents the patient's clinical status under the new MS-DRG system, and eliminating short stays," she says.
(For more information, contact: Toni Cesta, RN, PhD, FAAN, Senior Vice President, Lutheran Medical Center, e-mail: firstname.lastname@example.org; and Kathy Rickard, RN, BSN, MBA, Associate Director, Clinical Resource Management and Social Work, Hospital of the University of Pennsylvania, e-mail: email@example.com.)