By Jeanie Davis

Hospitals are struggling to meet the goals of value-based payment models. Value-based models are designed to improve outcomes, such as quality of care, satisfaction, and complications, while reducing costs. The impetus comes from CMS, which has set quality and efficiency standards for hospitals.

For decades, hospitals have worked toward these goals. “But many case managers might not realize that hospitals now face penalties if they don’t meet specific benchmarks,” says Beverly Cunningham, MS, RN, ACM, partner and consultant with Case Management Concepts.

Length of stay (LOS) and cost of care are two critical factors in the efficiency measure, she explains. Costs include both inpatient and post-discharge care costs. Hospitals are measured against benchmarks set by other hospitals across the region and nationwide, she notes.

CMS will penalize a hospital for high costs, hospital-acquired infections, ineffective discharge planning, and readmissions. For example, the CMS Hospital-Acquired Condition Penalty is a 1% reduction in payments for hospitals with lowest rates of performance — which can result in tens of thousands of lost revenue dollars over a year, Cunningham explains.

Each hospital’s performance is publicly reported, which can affect the hospital’s long-term financial viability. “LOS and cost per case are gauges of hospital efficiency, attracting managed care contracts and helping the hospital maintain a competitive edge,” she explains.

For example, a delay in patient ambulation can lead to pneumonia, delaying discharge. The increased LOS, cost for treating the pneumonia, and hospital-acquired infection will translate into lower efficiency, leading to penalties — evidence of lower value at that hospital.

Bundling payments is another CMS method for value-based healthcare, Cunningham explains. Some bundles are mandatory, others are voluntary. “Bundling incentivizes hospitals to aim for efficiency, as the financial risk is on the hospital,” says Cunningham. “This strategy also encourages collaboration across settings, and improves accountability and quality.”

One example of mandatory bundling is total knee replacement. A hospital will receive a certain amount for the procedure, to be paid to physicians, skilled nursing, rehabilitation, or home care. In addition to keeping LOS and costs under control, hospitals also must use the patient’s Medicare-allowed days efficiently.

Case managers can dramatically effect reaching their hospital’s goals via effective care coordination, says Cunningham. All members of the patient care team must collaborate to drive efficiency.

In addition, case management leaders must take steps to stay connected with hospital executives to know the trends in their hospitals, she adds. “If you don’t know, you can’t make any strategic decisions on improvements.”

Understand All Facets

Case management leaders can make it a priority to learn all facets of this value-based initiative, Cunningham says. They can assist each staff member in identifying interventions that can positively affect the value-based outcomes of their specific patient group.

• Assess patients carefully. Identify social determinants of health that may create barriers in discharging patients and implement solutions to remove those barriers that may increase LOS, increase cost per case, increase risk of readmission, and increase avoidable days.

• Focus on the hospital’s areas of risk. For example, if a hospital has established bundled payment patient groups, monitor and report cost per case, length of stay, readmissions, and avoidable days.

For example, a cardiac group must be monitored and the results reported, including any trends to the case management staff involved with cardiac patients. The case management leader must assist both RN case managers and social work case managers in building interventions that can positively affect those outcomes.

• Share outcomes with appropriate physician groups, and identify how the case management staff can collaborate with them to improve those outcomes. This process applies to all patient groups where the case manager can improve the patient’s care, Cunningham advises.

• Work with discharge facilities and services. Strive to transition patients to providers with fewest readmissions and complications of care, such as rehabilitation, long-term acute care, home care, or skilled nursing facilities.

“With the latest CMS final rule for discharge planning, we must involve the patient in their post-acute care decisions and provide them with providers that have the best outcomes,” she explains. “At the same time, we still have the obligation to allow choice. The final rule sets the scene for assisting the patient in making a more informed choice.”

Ensure their processes also are aimed at efficiency. “We must have people in post-acute settings who are aligned with our goals and working with us,” she adds.

Cunningham advises meeting with these post-acute resources regularly to discuss outcomes and reinforce the hospital’s mission of efficiency. “You want them to know how serious you are about this,” she says. Post-acute providers will be serious about their outcomes, as they also are in the process of transitioning to value-based payment.

• Track avoidable days. For example, if physical therapy is not available on weekends, track and report the delays. “When the case manager in each area reports their avoidable days, the aggregate can be very impressive,” says Cunningham. “This can result in the physical therapy department re-evaluating how they schedule their staff on the weekends.” Those delays can occur on a medical-surgical unit, orthopedic unit, cardiac unit, or surgical unit.

Also, if nursing is not ambulating noncomplicated patients, but depending on physical therapy, this should be addressed. “Nursing must understand how this delay in ambulation affects overall length of stay,” she explains.

• Track outcomes of interventions. “Too often, we put interventions in place and do not take the time to review our outcomes to see if we are making a difference,” says Cunningham. Discuss interventions with supervisors and ask for monthly outcome results to understand the effects of the interventions.

“Case management staff must understand the impact their interventions have on value-based reimbursement by seeing the trends (positive, negative, or flat) from their daily interventions,” says Cunningham. “This includes RN case managers and social work case managers.”

If not, they are just guessing about the effects of their interventions, she explains. “For too long, we have assumed that just because we do something, it yields positive results. That is not true.”