Case managers often encounter inefficiencies in their daily work due to poor communication and lack of actionable data. As one health system has learned, this obstacle can be eliminated with the right data metrics and dynamic dashboard.

It is frustrating for case managers to know that everyone possesses the skills and are doing the best job they can, but they are unable to set optimal priorities because they lack vital information, says Todd McClure Cook, MBA, MSW, EdD, vice president of integrated care management with Sharp HealthCare in San Diego. Cook led the creation of the Sharp HealthCare actionable dashboard.

Bedside case managers in particular need up-to-date information at their fingertips, Cook says. His leadership team created an actionable dashboard to identify core and critical indicators.

“These are indicators that would be important for case managers to watch,” Cook says. “It gives them data upfront on where they should put their priorities, and it engages them in the mindset of using and managing metrics.”

The metrics include patients’ length of stay, based on how many midnights they’ve spent in the hospital, and their status — inpatient or observation, he says.

Other dashboard data include whether the person had been hospitalized within the past 30 days. The hospital assesses whether patients are homeless, per a new California state requirement.

“We added homelessness to the dashboard. If an individual triggers as homeless, then they’ll show up on the dashboard and we can engage them in care planning,” Cook says.

The chief trigger for additional case management scrutiny is whether a patient has had four or more midnight stays in the hospital, he adds.

Once patients are identified as needing additional help, the goal is to set them on the best course of action:

• Collect data and create an actionable dashboard. A dashboard that case managers can access is only as useful as the timeliness and accuracy of its data.

If case managers do not have access to the most accurate data, then it’s not actionable, Cook says.

The question case management should ask about data is: “Can I go in at any moment, any time, and run this report, and it would have an immediate update so I know where I stand at that moment in time?” Cook suggests.

The dashboard should be continually updated, showing the newest high-priority case and eliminating the cases that have been resolved.

Case managers work to create a smooth transition and to remove all barriers to achieving that level of success. They usually check the dashboard at the beginning of the day and again after rounds, Cook says.

“They can print off a copy of their dashboard so they have it and use it as they work through their daily activities,” he says. “The dashboard is dynamic. There is new information all the time.”

Case managers can check midway through their day to see any dashboard updates, he adds.

• Identify patients in need of case management. The dashboard provides readily accessible data on patients’ length of stay, payer, admit date, etc.

“If you had been admitted to the hospital within the past 30 days, no matter what payer group, you’d be triggered on the dashboard,” Cook says. “Your type of visit would be on the dashboard: Was this an inpatient visit or observation status or emergency department visit?”

The dashboard also has a column for whether a discharge order is available.

“Similar to the initial assessment, the discharge order is a plan made at the end of each individual’s stay,” Cook explains. “It outlines what the care transition process looks like and what it will be in terms of supplies, resources, referrals, and what we have laid out as the plan of care necessary for the patient to be safe and sustainable.”

• Conduct initial assessment. There is a goal of completing initial assessments within 24 hours or one business day, he says.

The dashboard has a column that notes whether a patient’s initial assessment was completed. If not, then it becomes a priority.

The goal of the assessment is to collect data and provide a roadmap for what happens next with the patient. The dashboard highlights information that suggests issues for the case.

• Create discharge plan. Case managers also work with patients to determine what they are capable and willing to do in their own follow-up and self-care.

Clinicians can list a variety of actions the patient should take after leaving the hospital, but it is a waste of ink and paper if the patient is not able or motivated to follow through, Cook says.

“We center on not only what I want as a clinician but what the patient will agree to follow-up on — and that’s a big deal,” he adds.

An even bigger problem is if there is a discharge order but no discharge plan. The dashboard includes a column for these cases.

“If I have someone who will be exiting the board real soon and there is no plan written, then it means the individual will be at high risk of return or failure,” Cook says.

The goal always is to ensure a patient’s hospital stay is no longer than is absolutely necessary. Patient safety is at risk the longer a patient stays in the hospital, he says.

“If a patient’s stay is greater than four days, we typically want to know what the plan is, what the barrier to discharge is, and what is keeping them here,” Cook says. “How are we executing on that plan so we can get them to a safe environment, which is more appropriate for long-term care and recovery?”