Hospital leadership and staff need to look at new ways of delivering care to succeed in the rapidly changing healthcare marketplace as CMS and commercial payers move toward basing reimbursement on quality.

  • Pay-for-performance initiatives are here to stay even if Congress repeals the Affordable Care Act, experts predict.
  • As hospitals assume risk for patient outcomes for as long as 90 days after discharge, case managers have to identify at-risk patients and think about their care on a long-term basis.
  • Case management leadership needs to collect and report data on the hospital’s performance on quality measures, then develop and carry out process improvement projects.
  • Case managers should reassess their relationships with post-acute providers ,and track quality metrics and costs to ensure they are providing efficient care.

Case management directors can’t fix the problems they don’t know about and that’s why it’s so important to collect data, says Beverly Cunningham, RN, MS, consultant and partner at Oklahoma-based Case Management Concepts.

“Having good data is extremely important in today’s healthcare environment. Case management leaders need to understand where the glitches, such as avoidable days, occur, identify what caused them, and develop an action plan for improvement,” she adds.

Case managers should capture real-time data, says Elizabeth Lamkin, MHA, chief executive officer and partner in PACE Healthcare Consulting, LLC, in Beaufort County, SC. “In today’s world, we don’t have time to do a six-month retrospective report,” she says.

Instead of taking a shotgun approach to improving performance, hospitals should analyze all of the components of value-based purchasing and measure their performance in each of them. Use the data as a roadmap for setting priorities as you develop a quality improvement program, Lamkin says.

“These domains and the measures within them represent the future of healthcare reimbursement. Hospitals should be working on improving their performance on all of them through a team approach. Activities and improvement plans may be assigned to different teams but reported through one committee, such as the quality committee, to present the total picture to hospital leaders and medical staff,” Lamkin says.

For its Value-Based Purchasing program, CMS bases performance on a set of measures that are grouped into domains and determines scores by comparing a hospital’s performance during a “performance period” to how all hospitals performed during a baseline period, Lamkin says.1

Case managers can’t have much effect on some of the metrics on which CMS is basing payment, such as hospital-acquired infections, Cunningham says. But they can influence their hospital scores on the Medicare Spending Per Beneficiary and patient satisfaction questions relating to care coordination on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, she adds.

She suggests looking at your hospital’s Medicare Spending Per Beneficiary performance on the Hospital Compare website and comparing the scores to other hospitals in the area to see how your hospital stacks up against the competition. Understand what could be affecting your score. Poor scores could be linked to the post-acute levels of care, such as skilled nursing facilities, rather than your hospital’s inpatient spending per Medicare beneficiary.

If your scores look good compared to the national or state rate, don’t think you can rest on your laurels. Be aware that every hospital in the country is working to improve, Cunningham says.

“My advice is that hospitals should build an infrastructure within the organization and tackle these measures not as individual issues, but as systematic accountability,” Lamkin says.

Case managers should identify issues that indicate less than optimum patient care, aggregate them, and prepare monthly reports for the utilization committee and the quality committee, Lamkin says.

For instance, if there is a trend of delayed discharges because patients are waiting for a physical therapy evaluation, drill down and find out if it’s because there is a shortage of physical therapists, that they are available only 9 a.m. to 5 p.m., or another reason.

In addition, every facility should have a physician advisor to work with case management to engage medical staff to make improvements, she suggests.

“Leaders also have the challenge to make sure their staff is performing as their role demands. This means more than just collecting and reporting data. You have to put an action plan in place based on your results,” Cunningham adds.

Case management directors should educate hospital leadership about what is changing in healthcare, what payers are demanding, and what care coordinators can do to support the organization. Create metrics such as how care manager interventions resulted in lower cost per case to demonstrate your point, says Stefani Daniels, RN, MSNA, CMAC, ACM, founder and managing partner of Phoenix Medical Management, a Pompano Beach, FL, hospital case management advisory firm.

“Emphasize that care coordinators can do more than reduce bottlenecks. They can increase efficiency by reducing variation in treatment, and reach out to post-acute providers in the community and identify those who are willing to partner with the hospital to make sure patients don’t bounce back,” she says.


  1. Centers for Medicare & Medicaid Services. Hospital Value-Based Purchasing. Medicare Learning Network: http://go.cms.gov/1rqSbW.