Case management software: How to decide what’s right for you

It’s not just about the product; it’s about the fit

The market for case management software continues to experience significant changes as software vendors jockey to keep up with evolving practice patterns. At the same time, there aren’t as many standard case management software packages as there once were, says Diane Ward, RN, CCM, market segment manager for IBM Healthcare Solutions in Atlanta. "At one time, I could put my hands on 25 or 30 at any given point of time," she says. "Many have consolidated, and many have gone out of business."

Some people may be reluctant to purchase case management software because they don’t understand what the different products do. For example, some large firms try to sell large burdensome software systems with myriad functions, while some smaller firms market more specialized tools, such as a program to help stratify data on patient populations.

"Everybody sells to a different practice setting or sells a different kind of tool, and it creates a lot of confusion," Ward asserts. "Nobody knows how to integrate it into their already existing systems."

Hospital case managers should begin the process of selecting software by asking themselves several questions, Ward says. For example: What do you have now? How is it working or not working for you? What might your facility be looking for?

Vicki Mahn, RN, MS, vice president at ACS MIDAS+, a large management software company in Tucson, AZ, takes a similar view. "Before you go shopping for software, you need to be clear about what your goals are and what kind of organizational incentives are driving your need to automate. Basically, you need to define what it is you are trying to do."

The first key consideration for case managers is whether they are trying to manage a clinical population and, therefore, require information to help manage patients along a continuum of care, Mahn says. Conversely, case managers may require only information such as readmission rates and denial days to trend outcomes.

Many case management or care management plans in acute care environments are focused on improving quality of care, reducing readmissions, and shortening length of stay, while implementing best practice guidelines, she says. On the other hand, some case managers will be performing a more traditional utilization review (UR) management approach that focuses on authorization, tracking denials, and using criteria sets, she explains.

That UR approach is markedly different from a care management focus where clinical staff are assigned to follow patients across the continuum of care, whether that runs from the critical care unit to the telemetry unit or from the hospital to the nursing home and other community-based continuum, Mahn says.

"The bottom line is that the shopper of case management software must clearly know who they are and what their organizational incentives are," she asserts. "That is critical for a vendor to know in order to determine if they are a good fit."

Here are some of the latest trends in this area that case managers should be aware of.

Care management

Not long ago, the buzzword in health care was "disease management," with the aim of keeping patients out of the hospital largely through preventative medicine. Today, increasing attention is being paid to "care management." Health care professionals at provider organizations across the country now support the "care-based management of cost" approach of CareScience, an on-line care management services company in San Francisco.

"There is a fine line between care management and case management," says Barbara Doyle, MSN, CRNP, CareScience product manager. "But there is also a lot of overlap between those two worlds." According to Doyle, the biggest difference is that case management is focused on individual patients are financially focused on areas such as denied days and reimbursement, while care management takes a more population-based perspective with an aim to improve processes, outcomes, and patient care.

Even though both practices look at an individual patient with an eye toward improving care and reducing the number of days in the hospital, with care management, the individual patient is part of a population that can influence outcomes if care is rendered appropriately, she says.

Doyle, who is trained as an oncology nurse practitioner, says one difficulty in clinical care management today is that health care is largely divided into two camps. On one side are clinicians who resist the idea of controlling costs because they are focused primarily on patient needs. On the other side is management, which often notices patients who receive expensive tests.

As a result, hospitals increasingly are looking not only at individual costs but the productivity and the process behind them, Doyle says. For example, the most common complication in hospitalized patients is anemia, which is caused by routine blood draws. "Not only is that expensive, they often don’t really need it," she asserts. "You are putting them at risk for infection because you are puncturing their skin, as well as anemia because they are losing blood."

To solve this and similar problems, CareScience developed the Care Management System, an Internet-based care management solution that’s based on a proprietary model, based on research performed at the Wharton School of Business in Philadelphia, that identifies the complications patients experience. The product looks at resource utilization within the subpopulation of patients to determine what factors may be leading to complications. "One case study we did was fascinating," Doyle reports. That study looked at patients with intestinal obstruction and found that one of the major complications was congestive heart failure. When CareScience looked at resource utilization, it discovered that patients were receiving 2.0 to 3.0 liters of IV fluid a day for more than a week.

According to Doyle, patients were having fluid shifts during this postoperative period. "It was very clear that many of the patients who came in with intestinal obstruction were developing congestive heart failure from IV fluids."

The ability to identify problems and drill down to determine what is driving negative outcomes is critical for case management directors, Doyle says. "What we describe it as is a care-based management of costs’ approach as opposed to a cost-based management of care.’" She underlines the fact that clinicians respond to changes in their practice only when they have data.

Most of the more than 250 provider-based organizations that now support CareScience’s care-based management of costs approach are acute- care inpatient hospitals. Within each hospital, there typically are about six people using the software. Because it is Internet-based, the product can be accessed anywhere, Doyle says. "It is not hidden in the information technology department where a special request for data is required. People who need access to data are given access to data via the product." Access is being expanded because case managers and others require data regularly and on a real-time basis at the point of care, she says.

CareScience also offers a benchmarking product, which takes publicly available Medicare data at the facility level for different disease classes. As an adjunct to its care management system, it also offers National Comparatives, which allows hospitals to compare both their performance and resource utilization to a national sample.

Configuration

One of the major challenges facing case managers is that their needs are constantly changing. That often makes for expensive updates to the software they purchase. Mary Ellen Gay, vice president of IMA Technologies in Sacramento, CA, says her firm has several products that automate the care coordination for case managers while maintaining maximum flexibility and integration.

Notably, the company’s case management software program, called Casetrakker, is a platform rather then a content provider, she says. "What that means is that we tailor the software to each client’s needs without programming. We have our program tailored around their needs, including their pick list,’ their screens, and how many fields they have."

According to Gay, Casetrakker’s configurable design allows the customer to determine workflow and data definition of the system. All database modification is accomplished through configuration, not custom programming. This means existing data fields may be easily modified. "We change our software to meet their processes," Gay says. That can be accomplished rapidly. She notes that one health plan with 300,000 members configured its system and went live in less then 30 days.

Even though it is a completely custom application, Casetrakker can automate the process for clients and help monitor its appropriate use. For example, UR may show that length of stay exceeds authorization. "We can stop them from making mistakes such as that, even though all the fields are defined by the processes," Gay says.

The software performs care planning and assessments and tracks episodes of care. It also interfaces with Interqual and Milliman & Robertson on the criteria side and includes a built-in module where hospitals can create their own criteria. That has become a popular feature, Gay says. The software also does letters and reporting.

Casetrakker has a report-writer application that works alongside the program so it knows the structure of the database, Gay says.

Hospitals can design the reports themselves, or Casetrakker can do that during the implementation phase. That lets hospitals add reports as their requirements change in areas such as Medicaid. "They can update the reports themselves, and they do not have to pay for custom programming," she adds.

Discharge automation

Information system requirements span the continuum of care. But to date, there still is very little software available in the area of discharge planning. In fact, Mike Diamond, senior vice president for sales at Extended Care Information Network (ECIN) in Northbrook, IL, reports that 98% of hospitals do not have discharge management applications.

ECIN is seeking to remedy that by automating the discharge planning process. The firm was founded in 1995 by two physicians from Loyola University Medical Center in Chicago who realized there was a functional gap within automation pertaining to discharge planning, he says.

He points out that discharge planners operate in a very manual environment. That forces them to collect portions of the chart on paper along with certain demographic information from their information systems and disparate clinical information. Once they compile that information, they fax it to as many as a dozen providers to facilitate the discharge. "It is a laborious, tedious, and time-consuming process," Diamond asserts.

The ECIN process automates that process and compiles an electronic discharge profile of the patient, including demographic information and clinical information.

"We bring that all together in a profile within the application, and at the click of a button, we send out that information to subscribers," he explains.

The ECIN system then connects the acute care organization with the extended care providers in the marketplace through an ASP (application service provider) application. The firm uses a database and search engine to search extended care providers including nursing homes, home health, assisted living, and durable medical equipment (DME).

That database now includes more than 80,000 extended care providers nationally. ECIN connects the acute-care organization with any one of the extended care providers in a given marketplace. For example, a patient with a hip fracture may require DME, transportation, and a skilled nursing facility.

According to Diamond, ECIN has a research department that does nothing but research any given market to determine the number of extended care providers that exist in that market. When a new hospital contracts with ECIN, it starts to put an emphasis around that database beginning with the hospital’s list of preferred providers, he says.

Once a hospital is operational, the database is roughly 99% accurate, he says. Extended care providers that become subscribers to the application get the benefit of receiving that referral on-line.

That streamlines the process for case managers internally, Diamond says. It also allows them to distribute the information in an automated fashion even if the extended care provider is not a subscriber.

This process redesign has been accompanied by significant staff efficiencies. In fact, Diamond says some hospitals have seen more than 4,000 staff hours regained annually. A process that may take 50 minutes to identify an extended care provider and place the patient can be reduced to 10 to 15 minutes, he says.

Facilitating a more rapid discharge also creates a revenue opportunity for the hospital by reducing the "avoidable days" component of length of stay, Diamond says.

"They are typically looked at as a cost center," Diamond says. "But if they can help reduce avoidable days,’ now you are talking about real revenue for the hospital."

Integration

According to Mahn, any case management system that attempts to be a stand-alone product and operate in a "silo" from an information systems perspective is going to fail. "Case managers don’t need only their own data anymore," she asserts. "They need data from finance, surgery, quality, and infection control."

They especially require information from quality to learn if they are making things better or worse, she asserts. "Most case managers ultimately have to defend their value to their sponsoring organizations," she explains. If case managers are not able to demonstrate improvement in quality of care, cost, or patient satisfaction, their program will be perceived as "nonvalue added."

According to Mahn, case managers must acquire software that not only helps them to take care of patients but helps them access the kind of outcome information and process-of-care information they require for outcomes and evaluation.

That makes it critical to have a case management system that is integrated to the other parts of their delivery system. "It can’t just live on a little stand-alone server someplace and not talk to any of these other rich databases," she says.

That may explain why some of the smaller case management software companies failed, Mahn says. In many cases, they were not really information systems and they did not interface and leverage the data in other parts of the hospital, she says.

According to Mahn, successful software applications of the future will be those that can work within a rich repository of data. While they may not have fields to collect all the data, they will be able to accumulate it so that it is manageable and reportable. She says that will allow case managers to look at specific categories, such as pneumonia patients who may have been readmitted within 15 days, and determine their admission source, cost of care, how many may have been cared for by hospitalists as opposed to attending physicians, and similar questions. As these types of questions arise, and as case managers try to find their leverage points for managing care, they will need quick answers to those types of questions. "They don’t have time to go to a report writer and pose a question," she argues.

Case managers are not typically trained in informatics, which makes it difficult for them to phrase their question precisely and identify the population they are looking for, she adds. By the time they receive the report, it is often a week or two later, and frequently, they are forced to pose another question and wait for another report.

"That takes weeks, and that is going to kill case managers," Mahn asserts. "They must have a user-friendly way to get answers to those questions."

The effective case management systems of the future will be those that not only have fields to enter the patient’s discharge plan, destination, and criteria but also allow case managers to look at patterns in the larger population in order to focus resources, she says. "I think that is the kind of information that is going to be demanded by case managers in the future."

[For more information, contact:

  • Mike Diamond, Senior Vice President for Sales, Extended Care Information Network, Northbrook, IL. Telephone: (847) 790-8665. E-mail: mdiamond@ecin inc.com.
  • Barbara Doyle, Product Manager, CareScience, San Francisco. Telephone: (415) 371-8055. E-mail: mkrasner@carescience.com.
  • Mary Ellen Gay, Vice President, IMA Technol-ogies, Sacramento, CA. Telephone: (800) 458-1114. E-mail: MaryEllen@casetrakker.com.
  • Vicki Mahn, Vice President, ACS Midas+, Tucson, AZ. Telephone: (520) 296-7398. E-mail: vivki.mahn@midsinc.com.
  • Diane Ward, Market Segment Manager, IBM Healthcare Solutions, Atlanta. E-mail: Wardd1@us.ibm.com.]