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Data help case management demonstrate its contributions
Information shows drop in avoidable days, concurrent review denials
While many case management organizations are struggling to demonstrate the contributions they make to patient care, reimbursement, and cost containment, the integrated case management department at Sarasota (FL) Memorial Hospital has overcome the barrier and can demonstrate with confidence how it contributes to organizational success.
"We use our data extensively within the department as well as outside the department. We are tuned into goals and focused on achieving results," says Judy Milne, RN, MSN, CPHQ, director of integrated case management and quality improvement at the 828-bed county hospital.
The department has an integrated model that includes financial case managers who are RNs and do all the insurance contacts; clinical case managers (RNs) who focus on medical necessity and utilization issues; psychosocial case managers who handle discharge planning and other social work-related interventions; and physician advisors. Teams of clinical and psychosocial case managers are assigned by unit and work from their assigned nursing unit geographically.
"This has worked well for us because the case management staff build a solid working relationship with the nurses on the floor and the physicians who usually use that floor. The medical staff know the case managers and know who to look for if they need something," Milne says.
The clinical case managers, financial case managers, and psychosocial case managers all make entries in the database system daily as a routine part of their work.
When patients are transferred from one hospital unit to another, having concurrent data at their fingertips helps the case management team that takes over the patients’ care avoid duplicating medical necessity review or discharge planning activities that already have been done.
For instance, the patients may go from the intensive care unit or telemetry unit to the medical-surgical unit. If the team on one unit has started the discharge planning process and documented it, the case management team on the receiving unit doesn’t have to repeat tasks such as talking with the patient about being discharged to a nursing home.
The department focuses on discharge planning and utilization screening as well as ways to enhance efficiency and patient flow. It uses the data to demonstrate the impact of case management and to demonstrate that case management is a very intensive process.
"Our case management role is not substantially different from that described in a textbook. The real difference is that the staff are extremely engaged in achieving goals," Milne says.
Through the efforts of case management, the hospital has been able to lower its avoidable days rate from 45% to about 11%.
Sarasota Memorial was rated No. 1 in the country for Medicare efficiency by Milliman USA. "We have one of the best Medicare lengths of stay in the country, and we are 60% Medicare," she says.
By tracking the concurrent denial rates, the case management department has been able to show that it is overturning about 20% of concurrent denials and disagreeing with another 10% to 15%, flagging these for appeals.
Milne came to Sarasota Memorial Hospital in 1999, two years after the hospital hired Milliman & Robertson (M&R) of Seattle to redesign the case management structure.
There are about 50 full-time equivalent positions in Sarasota Memorial Hospital’s integrated case management department.
"I knew when I got here that I was going to have to be able to defend a department this large by being able to show our impact. That’s why the data are so clearly important," Milne says.
The hospital tracks its case management data using the Concurrent Care Management software sold by Eclipsys Systems and is one of the beta test sites for the new web-based version.
The care management software receives demographic and other stats from the hospital’s main computer system, including admissions information, transfer information, and insurance and billing data.
As the case managers and discharge planners do their own data entry, the whole picture of the patient emerges, says Greg Borden, CURN, CCM, systems manager for ICM/QI/infection control. "We don’t use all the fields in the program because we could easily turn our case managers into data-entry people. We minimize what we put in and maximize what we get out of it," he says.
Documentation begins in the emergency department (ED) and goes throughout the acute care setting, giving the hospital the ability to measure interventions and outcomes in all areas of care.
At Sarasota Memorial Hospital, senior management sets goals, which the case management department uses to establish its own goals and define the activities that help them meet the goals.
For example, hospital management sets a goal of budgeted length of stay, an overall hospital aggregate, and tracks the overall length of stay for the hospital on a monthly basis.
The clinical case managers work on the discharge goals on a case-by-case basis, using M&R guidelines to determine the proposed best practices length of stay for the patient’s diagnosis.
"We are really focused on proactive work, such as getting the patient type changed from observation’ to inpatient,’ or outpatient’ to inpatient,’ as appropriate. If you don’t get it right, you can’t bill for it," Milne says.
The database allows the department to track its impact on avoidable days and avoid denial of payment, as well as justify why certain things happen. If one unit’s length of stay increases, the case management department can pull out data to show the reasons why. For example, patients with certain diagnoses may be ventilator-dependent or need wound care and have no post-acute option in the community; a particular physician may be resistant to discharge planning; or it may be difficult to find a skilled nursing facility to accept an unfunded patient.
"Our data include the kind of detail that gives us the confidence to answer many questions," Milne says.
Addressing avoidable days
The system is set up to track avoidable days and classify them according to whether they are related to physicians or the system.
"We can aggregate our data by reason and link it back to the DRG and the physician," Borden says.
System avoidable days include reasons such as no beds available in the post-acute unit, no wound care facility in the patient’s community, delays in radiology and other procedures, or delays that occur because the cardiac catheterization lab isn’t open on weekends.
For instance, using the software, the case management department was able to identify a cost of $1.7 million in avoidable days because the cardiac catheterization lab isn’t open on weekends except during winter. However, a cost-benefit analysis showed that the cost of opening the lab on weekends exceeded the opportunity for savings.
"We’re going to continue to track those days. Right now, we feels like it’s not worth it from a financial perspective to add weekend services. The net dollar effect is that there would be no significant gain, and the patient outcomes haven’t suffered," Milne adds.
"Physician avoidable days" occur when the physician isn’t taking the necessary steps to progress the patient’s care and recovery or has failed to write a discharge order.
"The chart may not sufficiently represent what is going on with the patient. That’s why the case managers work with the doctors," Milne says. "If the chart doesn’t look like the patient meets the criteria for continuing to stay in the hospital, the case managers find out what else might be going on and prompt the physician to put it in the progress notes."
If a case manager is working with a patient who did not meet criteria for continuing to stay in the hospital, he or she talks to the physician, then goes into the computer system and places a referral for a physician advisor on a potentially avoidable day.
Based on the review, the physician advisor talks to the attending physician. The result of that discussion is either action by the physician involved or an avoidable day. The case manager documents the final outcome in the system based on physician advisor feedback.
"When we look at avoidable days, we can identify them by category and determine if there is an area of opportunity from an operational standpoint or look at diagnoses that seem to be problematic or physicians that have more avoidable days than their peers," Milne says.
The system gives the hospital the ability to break out avoidable days by physician and tally the cost of the avoidable days.
The hospital sends reports to each physician who had more than six physician-related avoidable days in a quarter, giving specific information, including the costs.
"When we did this the first time two years ago, we sent out 75 reports. Recently, we sent out just 10. We can see our system is working because we now have more compliance on the physician end," Borden says.
The financial case managers use the system to track concurrent denials when an on-site reviewer denies payment. The system generates a daily list on patients being concurrently denied.
"What we are trying to do is to resolve the denial before the patient is discharged. We try to take care of whatever we can before the patient leaves. You save money in the long run if you can fix it before it goes into the retro billing system," Borden says.
The case managers document when they get the denial overturned, when they agree with the denial, or when they disagree with the denial but were unable to get it overturned.
"We can show the value of the department by showing that we’re getting 20% of the concurrent denials overturned," Borden adds.
Three months later, when the denial letter comes from the payer, all of the information needed for the appeal is already in the system.
One advantage is that no one has to assemble information for the appeal long after the patient has been discharged. Another is that the hospital doesn’t waste its resources in appeals it is likely to lose. "If the case manager agreed with the denial, we don’t appeal it. We depend on their clinical expertise," he explains.
The hospital tracks retrospective reviews in the same way. Potential error due to status, such as observation or inpatient status, is another area of concern. "We try to catch them on the front end. We are constantly looking for it so we can get it changed to the appropriate status," Borden says.
"We can document how many we had per quarter and how much we saved by catching them. We can also generate reports showing the reason for the denial, whether it was a physician or a particular unit," he adds.