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Up-to-minute info allows you to head off trends
Case management outcomes can be a powerful tool for identifying the need for operational changes or process improvements throughout your hospital, as well as demonstrating the value of case management.
"By using our electronic case management system, we can track and trend data based on a variety of factors. Having up-to-the-minute data enables us to respond more quickly and try to head off trends that would be difficult for our hospital financially," says Kathy Rickard, RN, BSN, MBA, associate director, clinical resource management and social work at the Hospital of the University of Pennsylvania.
An electronic data management system is the key to being able to analyze data and create reports in a timely manner, she adds.
"We used to collect information on paper and cobble together a report. Now our ability to document concurrently and analyze data electronically has enabled us to notice trends and respond much more quickly than in the past," Rickard says.
Analyze your denials data to determine which physicians have a high number of denials and track denials by payer to determine if there are arbitrary denials; pass on the information to your finance department to use during managed care contracting, suggests Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY.
At the Hospital of the University of Pennsylvania, the clinical resource management department tracks denial patterns and obtains information on the cost of denials on a monthly basis from the business office. The information is used to spot trends among physicians or payers and take steps to correct problems, Rickard says.
"We break it down so individual physicians can see exactly what their performance is and the cost of the denials. We show them whether they had denied days or if the entire course of care was denied by the insurer," she explains.
The department notifies the hospital's managed care contracting staff when the hospital is getting denials from a particular insurer for a condition or procedure for which it previously was approved.
Measure the effect your physician advisor has on denials as well, Cesta says. Track the intervention of the physician advisor and whether he or she had an impact on getting it reversed.
You can determine the dollar amounts and what department is involved.
If you don't have a cost accounting system, it's impossible to determine the costs that case management has affected. Work with your financial department to determine the cost of care and use that to demonstrate an overall reduction of cost where case managers affected patient flow, length of stay, and resource utilization, she suggests.
At the Hospital of the University of Pennsylvania, the clinical resource coordinators go on daily rounds and notify the treatment team if an insurer is denying or downgrading a case.
"The clinical resource coordinators also work with the physician advisor to get any additional information needed that would keep the case from being denied. They work with the treatment team to get the patient on the right level of care as quickly as possible," Rickard says.
The department does the same with avoidable days, creating reports for physicians and working with them to align the resources and decrease avoidable days, she says.
Case managers should track avoidable days on a daily basis, by identifying gaps in care or delays in service through their own review process while they are making rounds, Cesta says.
Categories in your avoidable day report could include: internal system delays, such as waiting for an operating room; external delays caused by lack of available resources in the community; payer delays; and physician delays.
Break down your data. For instance, include a chart that shows the reasons for avoidable days. Break it down into categories, such as patient/family (no rehab coverage; family can't be reached, etc.); payer (Medicaid pending, insurance issues); and provider (delay in switching from IV to PO medication, covering MD will not discharge patients).
Drill down to understand the causes of delays and break them down into the time of day or time of the week. For instance, patients waiting for a particular service over the weekend affects length of stay as well as cost, Cesta says.
Administration can use the information you provide to make changes, such as considering extending the hours of the cardiac catheterization lab.
"Insurers expect a hospital to provide all the services 24 hours a day, seven days a week. It's a balancing act to figure out which services we need to have available. We track when certain procedures don't happen on the weekends and use the data to determine if it's physically and financially possible to increase the hours of that particular service," Rickard says.
Discharge delays may be due to the lack of resources in the community or the patient's inability to pay for them, or because physicians are not discharging patients in a timely manner, Cesta points out.
"Keep track of delays that are outside the control of the case management department but have an impact on your outcomes," she says.
Inappropriate admissions are going to be a focus of quality improvement organizations in the future, Cesta says.
Break out the inappropriate admissions from your denials and take a broader look at them and the impact they have on an organization, she suggests.
"A lot of times patients are admitted inappropriately for social reasons and the case managers have problems discharging them to a safe environment," she says.
Inappropriate admissions affect patient safety because nonacute patients are exposed to an acute care environment, she adds.
Use the data you collect to make changes in your case management procedures, Cesta suggests. For instance, although Medicare doesn't define the length of observation but says it expects in the majority of cases that the physician can make the decision about whether to admit the patient within 24 hours.
"If a hospital is exceeding 24 hours in observation in the majority of cases, the case management department should determine why and make changes. It's not good for the patients or for the hospital in general," she says.
Readmissions or emergency department visits are affected by other departments in the hospital but have relevance to case management, Cesta says.
Rickard's department tracks readmissions using a web-based tool that provides timely information about readmissions, which the case management team uses to find the cause of the readmissions and determine ways to prevent them in the future.
"Directors of case management need to know why patients are returning to the hospital because it may be an indicator of a failed discharge plan," Cesta says.
She suggests that case management directors review patients who are readmitted within 24 hours, the next day, within 15 days, and within 30 days and drill down to determine why the readmissions occurred.