As a case manager or an administrator of a case management program in your organization, you may be called on to participate in the evaluation of the case management model, its effects on the organization, or its effects on patient outcomes. You may have direct responsibility for evaluating the effectiveness of the model, the success of the case manager’s role, or the case manager’s performance.
Whenever possible, it is important to have an evaluation process and a plan set up before implementation or re-engineering your model or department. This is particularly true for those outcomes that affect the organization. Categories such as length of stay (LOS), third-party payer denial rates, readmission rates, avoidable delays, patient satisfaction, and cost of care should have baseline benchmarks against which the hospital can judge success or failure. Other indices, particularly those related to clinical or patient outcomes, will evolve over time.
Outcomes as Indices of Quality
Broadly speaking, outcomes can be grouped by those that have an effect on the organization versus those that have an effect on patients. These indicators may be the best measures of quality because they provide an understanding of the functioning of the organization and its effects on the product of services and patient care. Outcomes are the result of actions or processes. In patient care, they are defined as the goals of the healthcare process. A good outcome is one that has achieved the desired goal.
Case management, through the use of tools such as guidelines, multidisciplinary action plans (MAPs), and clinical pathways, and through case management team conferencing, allows healthcare providers to prospectively identify the expected outcomes or goals of care. There are no organizational or clinical processes or tasks that are carried out that do not have an expected outcome attached. Therefore, outcomes in their narrowest sense allow us to understand the effects on an individual patient, and in their broadest sense provide us with an understanding of the functioning (i.e., efficiency and effectiveness) of an organization or the healthcare system at large. These linkages provide us with an understanding of the structure (the organization), the process (the delivery system), and the expected outcomes (goals of care).
There are different types of expected outcomes of care. Some are related to the organization’s performance, but are not directly related to the patient’s health. Others are related to the patient’s health, but are not directly related to the organization’s performance. Still others are solely related to the clinical processes, meaning they are purely clinical in nature.
Case management outcomes can be categorized into the following four groups:
- productivity, and
- regulatory compliance.
Quality Outcome Metrics
Some outcomes directly affect the patient’s clinical quality or their perception of that care, such as the following:
- patient satisfaction,
- turnaround time for tests, treatments, procedures, and consults,
- discharge/disposition delays, and
- avoidable delays.
Understanding patient satisfaction with the care and services we provide helps us to improve those services over time and to continuously improve the patient’s level of satisfaction with the care they receive. Patient satisfaction data are either collected toward the end of the hospital stay or soon after discharge. All hospitals, and many other healthcare organizations, collect and monitor data on patient satisfaction. Unfortunately, there may not always be a mechanism for feeding that information back for the improvement of system processes or expected clinical outcomes as they relate to the case management department.
Turnaround Time for Tests, Treatments, Procedures, Consults
Turnaround time (TAT) can be used as a measure of an organization’s process improvement and efficiency after the introduction of case management. Facilitating care and managing the patient through the healthcare system should improve the TAT for completion of tests and procedures. The TAT should be measured from the time the physician places the order until the order is completed and results are recorded in the medical record. Acceptable timeframes should be decided in advance. For example, the completion time for CT scans may be 24 hours from the time the order is written until the results of the CT scan are placed in the medical record.
Monitoring of these periods can be done concurrently or retrospectively through the medical record. Concurrent data collection is always preferred because it is both more accurate and timely. If any problems or delays are identified, they can be addressed immediately. Retrospective data collection, on the other hand, may be more difficult because of lapses in documentation in the patient’s medical record, or simply the inability to obtain the necessary information. In addition, when problems are finally identified, it is late to try to resolve them. Delays in service turnaround time should be tracked and trended. High volume delays should be reported to the appropriate department. Examples include turnaround time for completion of tests, treatments, procedures, and consults, as well as the reporting of same.
Finally, relationships should be shown between the reduction in TAT and the LOS. As before, it may be difficult to prove sound relationships between LOS reductions and TAT because many other factors may have an effect on the LOS.
Readmissions have become a standard metric for case management. Because CMS reports them on a 30-day readmission cycle, most hospitals have begun reporting them that way. However, you may want to consider expanding your reporting to include the following:
- 24 hours, and
- same day.
These additional time frames allow for the identification of the root causes of readmissions that happen closer to the day of discharge. This methodology allows you to refine all readmissions into additional subsets to work on the causes and corrective actions.
Another method for reporting readmissions is by payer. Consider reporting in the following ways:
- Medicaid, and
- Managed care.
Looking at all payers will help reduce your overall readmission rates, as additional payers will most likely be applying penalties in the future. While not all readmissions are avoidable, some are. Understanding and tracking the hospital’s performance over time will ensure that everything is being done to reduce those readmissions that are avoidable.
Discharge and disposition delays are issues associated with the department’s inability to transition the patient out of the hospital in a timely manner. These issues may have to do with the availability of services in the community, family issues, financial problems, or physician issues. They may also be related to the performance of the individual case manager/discharge planner. To evaluate the performance of the case management department in terms of its discharge planning processes, the department should consider monitoring and analyzing these issues on a regular basis.
An avoidable delay occurs when what is supposed to happen does not take place. You can think of avoidable delays as a deviation from a standard, or omission of an activity or a step from a predetermined plan, norm, rate, goal, or threshold. Generally, variances are expectations that are not met. Avoidable delays are often the result of delays, interruptions, additions, or omissions of patient care activities and processes.
Avoidable delay data collection is important because it provides the basis for improvement in patient care activities, processes, outcomes, and quality. The mechanism of data collection is usually decided by the steering committee charged with implementing the case management model and the use of case management plans. Some institutions have delegated this responsibility to a case management department or a quality improvement committee/council. Regardless of who is responsible, the process should be made consistent across the various care settings that exist in the same institution.
There is no standardization in the method of classifying avoidable delays. They can be classified into different categories depending on the needs of your organization. Traditionally, the most common broad categories used to classify avoidable delays are patient, family, internal system, external system, and provider.
Financial Outcome Metrics
Many case management outcomes are directly related to the bottom line, or financial performance, of the organization. Examples of these include the following:
- cost per day/stay,
- length of stay, and
- third-party denials of payment.
Cost Per Day/Stay
Clinical cost accounting methods are being used more and more as a means of understanding not only hospital charges, but also the true costs of care. This information can be used to negotiate realistic and appropriate managed care contracts because the hospital understands exactly what costs are associated with the care of a specific population of patients. Cost accounting can also be used as a way of measuring the financial effect of case management on the organization.
Although understanding that reduction in LOS of a particular patient population is clearly important, it is also important to determine the amount of resources consumed in the management of that population. This issue has become critical now with the introduction of the Efficiency Measure, or “Spending per Medicare Beneficiary.” Organizations often focus on reducing the LOS but neglect to include an effort to improve the practice patterns related to tests, procedures, and treatments (pharmaceuticals and others), and eliminating the unnecessary activities. Sometimes they even distribute the same number of tests and procedures across the days left after reducing the LOS. This keeps the cost of care the same even though the LOS is reduced. Reducing the LOS but consuming the same amount of resources is not as valuable and should be avoided. This will not have the same long-term benefits of shortening the LOS but also reducing the amount of resources used in the care of that case type of patient.
The two main goals of clinical cost accounting are to identify the organization’s standard use of materials for a particular diagnosis-related group (DRG), and define the standard cost of each clinical service. An understanding of these costs allows the organization to assess its costs relative to the normal reimbursements, such as Medicare, Medicaid, and other payers. This information also provides a frame of reference or benchmark against which the organization can compare itself with competitors.
Internally, clinical cost accounting helps the hospital measure its internal treatment patterns. This information can be linked to the medical staff to determine which physicians are rendering the most cost-effective care. Allowing physicians to compare their cost per case with the expected cost or that of their colleagues may provide them with information they can use to improve their practice and in the revision of case management plans.
Length of Stay
Length of stay is a broad umbrella term that can be interpreted in ways to indicate the amount of time allotted to the care, treatment, or recuperation of a patient. In the inpatient setting (e.g., acute, subacute, or skilled nursing facilities/nursing homes) it can be measured by the number of bed days or the number of days the patient remains in the hospital. In the home care setting, it is calculated by the number of visits to the home and the number of hours or minutes per visit or the total number of hours. The LOS in the ED may be measured in hours or parts of an hour (15 minutes). LOS statistics are most commonly used in the hospital setting. They are often used as an indicator of the success of case management in conjunction with or in the absence of a cost accounting system.
To determine success or failure of case management and its effect on LOS, hospitals must have a clear understanding of what their LOS goals are and compare those with the current LOS statistics in the organization. Comparisons can be made between the hospital and a variety of benchmarks. The first should be the Medicare and non-Medicare DRG average LOS. Although DRGs are not the primary reimbursement system in every state, they are still used for analytical purposes. It is important to understand the history of the organization so that realistic LOS reduction goals can be set. The hospital should also benchmark against comparable hospitals. These hospitals may or may not be close geographically. National databases can be used for this purpose, such as the University Health System Consortium.
Third-Party Payer Denials
Third-party payer denials are a commonly used financial metric. Denials can be related to actual dollars lost and are easily measured and tracked. The department of case management should keep track of initial denials received as well as those lost or recovered after appeal. Trending of the data can demonstrate significant financial returns to the hospital. The data should be routinely reconciled against the data being reported by finance to ensure that both departments are reporting in similar fashion.
To monitor denial data, the case management department must record and enter accurate data in a timely fashion. The data should be audited periodically to ensure that it is accurate. The denials can be correlated to actual dollars based on the hospital’s specific reimbursement rates.
The following are ways in which denials can be aggregated and monitored:
- measure reductions in initial denials,
- measure reductions in final denials,
- measure percent reductions on each of the above over time,
- determine denial reversal rate,
- measure effect of physician advisor, and
- aggregate by physician/payer.
Productivity and Regulatory Metrics
Monitoring departmental compliance with regulatory indicators is important as a measure of compliance, but should be kept separately as an indicator and should not be included in your report card.
Regulatory compliance examples include the following:
- providing patients with choice lists for home care and nursing homes,
- appropriate documentation of discharge planning assessments,
- use of Condition Code 44,
- compliance with the Two-Midnight Rule, and
- appropriate documentation of patient discharge disposition.
Productivity measures are indicators of the volume of work performed by the department. Although they may give an indication of the amount and complexity of the work, these numbers alone don’t demonstrate the organizational outcomes, but rather the volume of the work itself. If monitored, they should be used for the internal evaluation of the department and of the case management staff and should be used within the department only. The department may find, however, that it needs to evaluate the work performance of individuals in the department to demonstrate the need for more staff members. In these circumstances, productivity measures are appropriate.
Case management leadership may consider using some of the productivity measures to evaluate staff members’ performance in conjunction with their annual performance reviews.
Examples of staff productivity measures include the following:
- number of patients discharged with services by type of service,
- number of case management assessments completed,
- number of case management assessments completed within 24 hours of admission,
- number of insurance reviews completed,
- number of interventions on avoidable day issues, and
- avoidable days capture rate.
Measuring your case management department’s performance can add value in many ways. It can help to demonstrate case management’s unique value in improving the cost and quality of care. It can help to make the case for additional case management resources when necessary. Finally, case management data can be used to identify areas of improvement for the department as well as the organization as a whole.