'Case management's day': Health care reform focus proves CMs' importance
'Case management's day': Health care reform focus proves CMs' importance
Make sure you have the staff to cover the load
There's little doubt that as health care reform rolls out and all payers tighten their reimbursement, hospitals are going to depend more and more on case managers to help them ensure that patients receive the appropriate services in an efficient manner and safely move to the next level of care.
"I firmly believe that this is case management's day. Hospital administrators are focusing on all of the metrics that case managers affect," says Beverly Cunningham, RN, MS, vice president, clinical performance improvement, Medical City Dallas Hospital, and partner and consultant in Case Management Concepts LLC.
Hospitals already are feeling the effects of the Medicare Recovery Audit Contractor (RAC) and the Medicare Integrity Contractor audits, as well as audits from commercial payers in some areas, she says.
Under new regulations from the Centers for Medicare & Medicaid Services (CMS), hospitals will get lower reimbursement if patients develop a hospital-acquired condition or if the hospitals' 30-day readmissions fall in the upper percentiles compared to their peers, she says.
"Usually as Medicare goes, Medicaid goes, and commercial payers follow suit. Eventually, all payers will follow what Medicare is doing and reduce reimbursement for readmissions and hospital-acquired conditions," Cunningham says.
Health care reform legislation calls for a decrease in reimbursement for each DRG every year, beginning next year, she adds.
At the same time reimbursement is dropping, the average length of stay for patients is increasing. Between 1998 and 2003, the average hospital stay increased by 8.9% to 5.7 days overall in the United States. In New York, it went up 8.3% to 7.2 days.
The length of stay has increased because patients are more complex and because as more and more appropriate patients receive observation services rather than being admitted, many one-day and two-day stays have been eliminated, Cunningham says.
"The biggest challenge for hospitals and case managers used to be to avoid denials. Now that hospitals are going to be receiving reduced reimbursement, case managers have to be able to respond to that as well. Over the years, our strategy is going to have to be to assure that the length of stay decreases and that each patient receives the appropriate resources," she says.
When new payer requirements come along, hospital administrators often give the job to case management, rationalizing that they can do it because they're already in the charts, points out Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, and partner and consultant in Case Management Concepts LLC.
"The more functions you give a hospital case manager, the fewer patients he or she can manage. Taking on more and more and not being able to adequately complete the work taken on is not positive for the department or the organization. The problem is that case management leadership often doesn't know how to demonstrate that their staff can't take on yet another task and be successful. We are our own worst enemies because we never say no," she says.
Part of the problem is the lack of understanding on the part of hospital management of case management case loads, Cesta adds.
"Case loads are no less important in the case management department than they are in the nursing or physical therapy department. There's only a quantifiable amount of work that any one person can complete efficiently in a day," she adds.
People at the executive level of hospitals often don't understand the level of volume and the level of work that case managers can handle efficiently and effectively, Cesta says.
"Case managers have to make a case for adding staff by showing the value that case management brings to the organization. We need to show the relationship between how the work is deployed and how staff intervene to optimize resources on a case-by-case basis," Cesta adds.
Case management case loads can't be considered in isolation because they depend on the hospital's case management model, Cesta says.
Some models require case managers to complete multiple tasks. In other models, case managers concentrate on only a few tasks. Case loads will vary accordingly, she says.
Among the roles that often become part of the case managers' duties are concurrent core measure review and clinical documentation improvement.
Neither of these roles should be the responsibility of case managers, Cesta says. Instead, consider a position that combines clinical documentation improvement with concurrent core measures review.
"So many times the charts to be reviewed for both of these processes are the same," she says.
Integration is the key to an effective and efficient case management department, Cesta says.
"Traditional case management models are fragmented and expensive, with the potential for overuse and underuse. Partial integration concentrates on two roles. Full integration is the most efficient and the most cost-effective but must be balanced with appropriate case loads," Cesta says.
In the integrated model, a single case manager is responsible for all functions, including patient flow or clinical coordination, utilization management, discharge planning, variance tracking, and quality management. The advantage is that it integrates previously disconnected functions, she adds.
In an integrated model, a clinical documentation specialist handles chart review and physician queries, concurrent core measure reviews, and queries to physicians and nurses. Social workers are responsible for screening, assessment and planning, brief therapeutic interventions, continuum of care planning, and crisis intervention.
In this model, social workers and nurse case managers share discharge planning duties, with the RN handling clinical discharge planning and the social worker psychosocial aspects of discharge planning.
Cesta recommends a case manager case load of 15 for medical units, and 20 for surgical, critical care, and acute rehabilitation for departments using the integrated model. Case managers on the pediatrics and maternal-child unit should have a case load of 25, she says.
An alternative model, the collaborative practice model, separates the clinical and "business" functions of case management into separate roles and partners with social work to achieve results, she says.
In this model, case managers perform risk screening, assessment and planning, coordination of care, resource utilization, and outcome management.
A utilization/DRG manager primarily works the business side of case management, including reviewing documentation and acting as a liaison between team members, payers, and regulatory entities. Tasks include medical necessity screening, authorization and certification, observation status compliance, DRG assurance, and denials management.
The model includes clear criteria for social worker referrals, such as crisis, substance abuse, and legal issues. Social workers focus on the core social work issues, such as screening and assessment, crisis intervention, continuum of care planning, and assisting with discharge planning for select patients.
Cesta recommends a case load of 15-23 for case managers in the collaborative practice model and a case load of 20-40 for the utilization/DRG manager.
Most case management departments are going to need more staff to adequately perform their increasing duties, but how do you justify it to a hospital administration that is pinching pennies just to stay afloat in today's tightening health care marketplace?
"Case managers bridge the gaps between quality, outcomes, and finance. They have to demonstrate what financial and bottom-line indicators they affect; what quality indicators, regulatory indicators, and patient satisfaction indicators they affect," Cesta says.
First and foremost, case management directors need to have a business plan in place in order to justify the staff they need to properly and thoroughly do their jobs, Cunningham says.
"Case management directors can't just go to the administration and request more staff. Instead, they have to put the request in language that people in finance understand and make the business case for more staff," she says.
That means tracking what you do every day, determining the impact that case management has on the financial health of the hospital, and creating reports to show to administration, she adds.
"The hospital chief financial officer is likely to have run the numbers and know how much the hospital has to save in order to make up for the cuts in reimbursement that are coming along. It's up to the case managers to show what the case managers can do to help the hospital meet its goals. Then show what the losses will be if the case managers are unable to do the job because they have too much on their plate," Cunningham says.
Case managers need to know what the business outcomes are as related to the goals of the hospital and make the case by showing what case managers can do to affect the outcomes.
"Take a look at where the hospital is headed and show them what case managers can do to take them there. Case management directors should be creating a business plan every year that is aligned with the goals of the hospitals," Cunningham says.
If you don't know how to create a business plan, look for help from the strategic development office or the CFO, she says.
Look at your hospital's goals and determine what case management contributes to meeting those goals, Cunningham suggests.
"Every hospital tracks length of stay and patient days and many other metrics, but not everyone shares all that information with the case management department. It is essential for case management directors to find out what the business numbers are as they are related to case management," she says.
Equate the case management role and what is expected of them to priorities in the hospital, she says.
Make sure the data you present to the administration are clear and concise in a format they can understand and that relate to the key indicators measured by the hospital, Cunningham says.
"Remind your leadership that some case management tasks are mandated through Medicare's Conditions of Participation. These include discharge planning and utilization review," Cesta adds.
At Medical City, the case management department focuses on length of stay, denials, patient satisfaction, and readmissions. The quality department coordinates hospital-acquired condition rates, Cunningham says.
"In my business plan, I need to know who has ultimate responsibility," Cunningham says. For instance, the quality department may be responsible for readmissions and hospital-acquired conditions. I determine what my department will also contribute to reducing readmissions and hospital-acquired conditions," she adds.
To be effective, case managers must collaborate with all departments in the hospital, Cunningham says.
"In the past, the hospital revenue cycle was more a concern of patient access, health information management, finance, and case management. Now, we're adding in quality, physicians, nursing, and ancillary care providers. These also make a difference in readmissions, hospital-acquired conditions, and lengths of stay," Cunningham says.
(For more information, contact: Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, e-mail: [email protected]; Beverly Cunningham, RN, MS, vice president, clinical performance improvement, Medical City Dallas Hospital, e-mail [email protected]; To purchase "Case Management 101:Roles and Models for Hospital Case Managers," a webinar by Cesta and Cunningham, visit http://www.reliasmedia.com/cart/?prid=4008&mtid=a&adit=4008.)
Comparison of two model designs Integrated Model Case Manager Clinical Documentation Specialist Social Worker |
Collaborative Practice/Triad Model Case Manager Social Worker Utilization/DRG Manager Source: Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, and partner and consultant in Case Management Concepts LLC. |
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