Determine what to track and how to track it

Outliers, costly diagnoses are a place to start

Before you start your outcomes measuring program, you need to decide what you’re going to track and how you’re going to document your savings.

Mary Jane McKendry, RN, CCM, MBA, director of education, training, and consulting for McKesson and is president-elect of the Case Management Society of New England, suggests starting with your frequent diagnoses, your costly diagnoses, or your outliers, and track what you do for these, what your interventions are, and how the interventions affect the outcome.

One measure would be to pull data on the "frequent flyers," those who had three or more ED visits for the same or a related diagnosis in the past five months, she says.

Look at what is going on with each patient. Assign them to case management and have the case manager do a typical assessment and track all their interventions.

Find out why their patients are having trouble with their treatment plan and why they are making ED visits. It may be that they can’t get their medication or they stopped taking it because it made them sick. It could be that they don’t know how to monitor the signs and symptoms of their disease and, when they call the physician’s office, they are put on hold and they don’t like to wait.

Interventions may include making weekly calls to members and helping them overcome their problems in compliance. If a client says she isn’t feeling well, the case manager may counsel the client to see her physician and help her get an appointment before her condition gets worse. The case manager may help clients get their prescriptions filled or empower them to ask questions of their providers.

After a period of time, say six months, measure how many urgent visits they made, compared to the six months before they were in case management.

"The case manager can show that the calls she made to the patient can be related to a decrease in urgent visits, which saved this amount of money," McKendry says.

Another way to identify the impact of interventions on outcomes is to focus on several diagnoses and compare the data before and after you began case managing the patients.

Start out with the two or three diagnoses you know you handle well. They could be a diagnosis such as myocardial infarction or diabetes, where there are a lot of protocols.

Then take another diagnosis where the patients are difficult to manage, where some are compliant and some aren’t, such as congestive heart failure.

Pull the data for the year before you started tracking and compare them to the current year. Track how long the average person stayed in the hospital or how long it took for them to move through the continuum of care.

You might start out with the most expensive diagnoses or begin with two or three high-cost diagnoses you know you manage well.

Start tracking these diagnoses and add to the list of diagnoses to track after you have figured out the best way to track interventions and outcomes with the first few.

For instance, you could start making weekly calls to all congestive heart failure patients to make sure they know how to measure their weight and check their respirations. Prompt them when it’s time for them to see the physician.

Measure the interventions against the previous six months. Then you might include working with the hospital case managers to make sure the patients are educated about their disease and linking them to a disease management program.

"Case managers do this with every congestive heart failure; but in the past, they haven’t measured it," McKendry says.

Look at the population that has had these interventions and that which has not and do a comparative study.

When you look at the population you have managed and see that some still have frequent admissions, look at the individual patients to see what is going on and whether you need to change your approach. For instance, if the case managers are just sending postcard reminders to patients, you might consider calling the outliers.

After you change your interventions, measure again to see if they work.