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When tracking outcomes, start with job description
Show what you contribute to your organization
More and more often, case managers are being called on to demonstrate their value by reporting on outcomes. But there are no hard-and-fast rules as to what outcomes to measure because they differ from organization to organization, says Mary Jane McKendry, RN, CCM, MBA, director of education, training, and consulting for McKesson Health Solutions.
McKendry is president of the Case Management Society of New England.
“Case management is considered a value-added service and in most venues, it’s not reimbursable. Hospitals or health plans usually can’t charge for case management services. What the organization needs to know is what value you bring to the table,” she says.
Case managers should be able to track outcomes that clearly demonstrate the return on investment for their services and show how they assist their organization in meeting its goals.
For instance, the organization may be focusing on quality or complying with Medicare and Medicaid regulations — or both.
Before they can start tracking outcomes, case managers should be able to recognize what they are required to do from multiple levels, McKendry says.
Case managers should start by understanding the standards of practice from national organizations and how they fit into the job definition.
For example, look at what the job entails, the rules case managers must go by, professional licensure requirements, the expectation of the employer, and the laws and regulation that apply to each particular practice. Examples include Medicare, Medicaid, workers’ compensation, and the Americans With Disabilities Act.
“Case managers should link what they do for their job with what the national organizations say and evaluate where there are synergies,” she says.
Case managers should ask themselves what their organization expects of them. Is your focus to decrease cost and maintain quality or to maintain costs and improve quality? Does the organization have any major compliance issues with Medicare or Medicaid regulations that case managers can help with?
“The biggest problem case managers face in managing outcomes is that they touch people in so many different ways that each case manager almost has to create a unique set of outcomes to document,” McKendry says.
Once the case managers determine what outcomes to measure, the next step is to develop an easy and practical way to document what they do and to compile an outcomes report.
McKendry offers this example:
Your goal is to decrease costs, but first you have to understand why costs are out of line and put in place a plan to address them.
Frequent flyers, or people who have repeat admissions to the hospital or the emergency department, may be one avenue on which to focus.
As a case manager, you may want to have a discussion with the admitting physician to see if there is an alternative to admitting the patient to the hospital.
Find out if the patient needs more support at home or simply doesn’t know how to take his or her medication regularly. Look at what you can do to cut down on admissions. For instance, a patient may be medically complex and may need home health services or to be in an assisted living center where he or she can be monitored regularly.
Track each individual case over time, then compile information on case management interventions and the resultant decrease in admissions. This type of outcome demonstrates the value of case management involvement.
“I’ve found out through my audits of hospitals and health plans that the patient population is getting sicker. Data related to this fact is another way both case managers and utilization managers can show the value they bring to the table when thoroughly documenting their work,” McKendry says.
If case managers document the trend toward sicker and more medically complex patients, and the level of services these patients receive, they also can document improvements in quality or drops in cost — such as decreased readmissions — as a result of case management interventions, she points out.
For instance, case managers could document the educational support for patients as they go to the next level of care, admissions to wellness programs, and the times that they proactively get patients in to see physicians so they don’t have an emergency admission.
Here’s an example from McKendry: You assess Mrs. Jones and find she has been admitted to the hospital three times in 12 weeks for the same diagnosis.
This is the time to alert your risk manager and the physician. Talk to the patient and find out what her problems are.
Mrs. Jones may not be getting her prescription filled or may not be eating well. Maybe she doesn’t drive and can’t afford a taxi to pick up her medicine and doesn’t know that some pharmacies will deliver.
Mr. Jones may not be aware of the health plan’s or hospital’s help line she can call with questions or may live alone and call the ambulance whenever she feels sick because she has no one else to call.
The case manager can document what she did (their interventions) and address issues such as cost, quality, and compliance with federal regulations that prohibit hospital admissions for social reasons.
“Case managers need to create metrics for themselves, to look at each individual case and identify issues that impact quality and cost of treatment,” she says.
For instance, if you have managed 350 cases and 40 of them were people with diabetes, document that you connected them to a diabetes educator, helped them set up a self-care plan, and taught them how to monitor their lab values and other health factors.
Look at similar medical records for one or two previous years and compare patient outcomes and document any decreases in admissions or urgent care for those 40 patients after case management interventions were started. Or you can document an increase in the number of patients who received retinal examinations or had their hemoglobin A1C levels checked after the interventions started.
Look at what you did in each case and break it down.
The challenge is coming up with a way to pull data from your records and turn it into objective information, McKendry says.
“Case managers have to learn to decrease their free text in the documentation reports and increase their objective indicators,” she adds.
For instance, McKendry says, if your organization’s goals are to address cost and quality, pick some areas in which to measure outcomes. It may be decreasing readmission, increasing use of observation status, or increased use of home support services instead of hospital admissions.
Look at the whole population you managed over the past year and try to stratify them to create specifics to your population.
Study admissions for various diagnoses and come up with a way to address them.
“Look for commonalities, such as a lot of people with diabetes or chronic obstructive pulmonary diseases. Document that you were able to direct them into disease management programs or outpatient screening programs,” she suggests.
Document when you give patients instructions on who to call if they have a question, or when they should call you with a health question so perhaps, you coordinate a visit to a physician before their problem is bad enough to send them to the emergency department.
“There are a lot of outcomes that case managers can demonstrate from both a quality and cost perspective,” McKendry says.
For instance, if an urgent admission costs an average of $5,000, and you diverted 80 of them in one year, you save your plan $400,000. If you tabulate the savings from all the case managers in your department, it can add up to a large sum each year.