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Hospital system measures value of CM department
At a time when case management departments all over the country are facing cuts in staff or just remaining stable, DCH Health System in Tuscaloosa, AL, recently added four 0.7 FTEs to the case management departments of its two largest hospitals.
The new staff are clinical documentation specialists who handle clinical documentation review and are now taking on the job of concurrent reviews for the Centers for Medicare and Medicaid Services' core measures quality reporting initiative.
Brian Pisarsky, RN, BS, ACM, CPUR, director of case management services at DCH Regional Medical Center and DCH Northport Medical Center, attributes the increase in staff to an extensive data tracking system that measures case management interventions, adds up their value, and creates a monthly report for the hospital's administration.
"If you can justify and show the value that case management brings to the table, you can get the staff you need. But you have to have specific data in order to be able to justify it. We apply dollars to every single category of case management interventions. We let the administration know that if we weren't here and were not able to intervene, at minimum, this is how it would affect reimbursement at this hospital," he says.
Pisarsky's department performs multiple monthly audits to ensure that the hospital is compliant. These include one-day stays, patient choice, three-day qualifying stays, readmissions, MS-DRG pairs, and accuracy of documentation.
"We never compromise the care of the patient. We continually strive to find ways to positively impact the care of the patient while monitoring the financial impact of our processes," he adds.
DCH Regional Medical Center is a 580-bed regional facility that receives referrals from seven counties. DCH Northport Medical Center is a 204-bed acute care hospital with both inpatient rehabilitation and psychiatric specialty units.
Case managers are in charge of care coordination; creating the discharge plan; and utilization review for Medicare, Medicaid, and self-pay patients. They are unit-based and have an average caseload of 24 patients.
The 53 employees in the case management department at both campuses include utilization review coordinators who handle commercial utilization review, social workers, infection control, a hospital-to-home case manager, clinical documentation specialists, and two nurses who handle inpatient and outpatient denials and appeals.
As one way of tracking its progress, the department develops goals for each year and monitors them on the case management software system's electronic dashboard.
"Everyone in the department is aware of our department goals, what we are measuring, and our progress toward meeting each goal," Pisarsky says.
For instance, each year, the team looks at the percentage of patients in observation status compared to the same time frame the previous year and sets a goal based on those data and national standards.
Among the department's other goals listed on the dashboard are the case-mix index, the base-mix index, the average length of stay for all patients, the length of stay for patients transferred to skilled nursing facilities, and the length of stay for patients being discharged with home health.
If the goal is being met or exceeded, the dashboard is green. If it varies by 5% either way, it is yellow. When the department fails to meet its goals, the dashboard is red.
Data are available through the computer system and a printout is given to all case managers every month.
The hospitals use an electronic case management system, which, in many cases, can automatically calculate the revenue generated by the case management intervention when the case managers enter it on the wireless laptop computers they take with them as they complete their work.
Pisarsky uses the data to create monthly reports that he shares with the administration.
"One of the most important things the case management directors can do to prove the value of the department is to apply dollars to what the case managers do," he says.
For instance, to demonstrate the value of the work of the clinical documentation specialists, the department measures the capture rate of complications and comorbidities (CCs) and major complications and comorbidities (MCCs) in the MS-DRG system and computes how many CCs or MCCs are added after the clinical documentation specialists review the case with the physician to make sure the documentation is accurate and complete.
By comparing what the physician originally wrote in the record with documentation that was added after the case management query, Pisarsky is able to demonstrate the increase in reimbursement due to case management efforts.
"We compare the original MS-DRGs based on original documentation with the MS-DRG after we intervene and tabulate the difference in reimbursement. This is entered into a spreadsheet that is part of the department's monthly report to the administration and the entire case management department. Some queries do not influence reimbursement but the documentation specialists make sure that all documentation is accurate and complete," he says.
By tracking the response rate to queries from physicians and the number of queries issued by case managers and comparing the data to previous months, Pisarsky can determine that the case managers are querying the physicians appropriately and are getting answers to their queries.
The department measures both the case-mix index and the base-mix index at both facilities as part of its efforts to document case management's effect on the bottom line.
The base-mix index is made up of all the medical MS-DRGs and excludes surgery and other hospitalizations that do not involve medical illnesses.
"The case-mix index includes all admissions and can be dramatically influenced by the number of surgeries the hospital performs each month. Case managers can't impact the number of surgeries, but with medical admissions, they can make sure the medical record captures all the documentation necessary for the CCs and MCCs that show how sick the patients really are," Pisarsky says.
The case managers review all patients initially placed in observation status and contact the admitting physician if the patient meets inpatient status. If the physician changes the order from observation to inpatient, the additional revenue generated is added to the case management intervention total.
The department also conducts preregistration utilization review to make sure that all patients who come into the hospital for planned procedures are admitted in the correct status.
For instance, the utilization review specialists check to see that patients receiving procedures on Medicare's inpatient only list are admitted in inpatient status. If not, they get the physician to change the status before the procedure is done so the hospital will get paid for the procedure. That amount also is included in the case management outcomes data.
"When our physician advisor works with the admitting physician to expedite a discharge, we count it as nonavoidable day. If the case manager didn't intervene to call in the physician advisor, the expedited discharge would not occur," he says.
The department tracks admission length of stay — the number of patient days divided by the number of admissions in a month — and compares it against benchmark data.
"We also look at length of stay for patients discharged to skilled nursing facilities and home care and benchmark against ourselves because we cannot find other hospitals that track this," he says.
Pisarsky takes the number of patients discharged to skilled nursing facilities and divides it by the number of days. He does the same for home care.
"We want those patients moved to skilled nursing care and home care as quickly as possible," he says.
Hospital-to-home case manager
In fact, the health system recently added a hospital-to-home case manager to make sure that patients who are appropriate for home care receive those services and to find ways to decrease readmission rates, he adds.
The case management department has bimonthly meetings with representatives from local nursing home and home care agencies to discuss barriers to discharging patients.
"We have a continuing process improvement project going on everything we measure," he says.
The department deals with potential denials and appeals both before and after discharge.
Utilization review nurses conduct concurrent interventions with the insurance companies on potential denials.
The department's full-time inpatient appeals nurse reviews all inpatient denials. The denials or underpayments are sent for review and appeal if appropriate.
"If she intervenes, she talks with the nurse or physician at the insurance company and provides clinical information that is beyond the knowledge of the staff in the business office," he says.
The nurse tracks her interventions and their results on a monthly basis and is able to provide a dollar figure on additional revenue the hospital receives as a result of her actions.
"We do exactly the same on the outpatient side. The outpatient appeals and denials management nurse reviews the cases and makes sure we get paid. We measure every dollar generated by these two nurses and report it monthly to the administration and the staff," he says.
Case managers participate in the hospital's weekly length of stay meeting, attended by the vice president of medical affairs and the physician advisor, and share their concerns and challenges with the rest of the staff.
"We discuss every patient who has been here for six days or more and the barriers to discharge. We discuss what issues the case managers are encountering and what they need to be able to intervene," he says.
(For more information, contact Brian Pisarsky, director of case management services, DCH Regional Medical Center and DCH Northport Medical Center. E-mail: email@example.com.)