Document outcomes to prove your value

Tallying soft savings is not enough anymore

Today’s case managers need to understand outcomes and track them in order to prove that their interventions have value, says 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 in Hampstead, NH.

"Case management is at a crossroads. We know that case management brings something valuable to the table, but now we need to clearly define the ways to accurately measure the results of our interventions and design a way to report on it," she says.

Outcomes result from interventions

She is a member of the Case Management Leadership Coalition (CLMC; www.cmleaders.org), a group of leaders representing a broad cross-section of the case management field, formed to address the challenges facing case managers in a changing health care environment. McKendry is on the CMLC task force researching quality and outcomes reporting metrics and return-on-investment tools and strategies.

Simply put, outcomes are the end result of the interventions a case manager performs, McKendry says.

In the past, case managers have faced challenges in documenting their interventions because most often they didn’t have the software to use, there were no processes in place to document outcomes, and there were no hard-and-fast rules about what to document.

"Case managers have faced challenges in documenting their outcomes because they didn’t have the supporting software or hard-copy applications to track outcomes, or they were too busy to document them," she says.

Cost-benefit analysis

McKendry recalls that in a previous job, she realized that she was able to call as many as three clients in a 15-minute period and make really good decisions and/or suggestions about the clients’ care, but that it would take an hour or longer to document the discussions.

Most case managers who document their outcomes have had to learn how to do it by the seat of their pants, she adds.

In many cases, the interventions have been driven by what the organization wanted the case managers to do. For instance, in workers’ compensation, many case managers are pressured to document return to work, and companies tout their success in returning people to work.

"Nobody was measuring successful return to work. If we got them back to work quickly and they weren’t ready and they were re-injured, you wonder how successful the intervention was," McKendry adds. The better outcomes to measure would be successful return to work, she says.

Some case managers have been doing cost-benefit analysis and documenting soft savings, but many people haven’t paid attention to this because it hasn’t been hard dollars, she adds.

The challenge is how to take the global case management strategies such as assessment, planning, implementation, and evaluation and build models that work for organizations to track what case management interventions are done, what outcomes should be observed, and how to appropriately report on them, McKendry says.

"Chances are that we document only the most critical interventions. We are making interventions we can’t quantify or not documenting what we are doing," she says.

It is critical for case management departments to be able to take what a typical case manager does and link it to cost savings or good outcomes, she adds. The information has to be in a form that can be used to generate a report that documents the related savings.

"It happens every day. The patient has a concern. The case manager discusses it and directs them to the right care, helping them avoid an emergency room visit or exacerbating their condition so much that he or she needs to be hospitalized. These are important interventions, and we have not done a good job of documenting them, or we document them in a narrative form," McKendry says.

McKendry suggests that case management directors collaborate with their information technology staff to create a way to measure outcomes and quantify the impact of interventions. Some case management departments have used an off-the-shelf spreadsheet program to track their interventions, she adds.

If your computer technology isn’t sophisticated enough, create a paper worksheet that case managers can use to jot down their interventions. The information can be put into the organization’s data warehouse, she adds.

Start by listing the typical interventions that case managers do in a way that makes it easy for the case managers to check them off. With a software application, there can be a screen with places for the case managers to check off what they did.

Even with paper copies, it’s easier to document in an outline format than in a narrative form, and it is easier to generate reports later on, she adds.

Examples of hard savings

Every time a case manager does something for a patient, he or she should fill in the data and transmit them to wherever your data are stored.

Come up with a way to measure how a case manager’s interventions have an impact on the quality of life, clinical, and financial aspect of care.

Link what you do to those three markers: Clinically, the patient is doing what he or she needs to do and knows where to get help. The patient’s quality of life is better because he or she feels better. The company is financially better off because the patient requires less urgent care and fewer visits to the physician’s office.

"Case managers have to be able to define in some kind of format the things they do, when they do them, and the impact they have. It’s not just that they make calls, it’s what they learn when they call, and what they then do with the information," she adds.

For instance, if you call members with congestive heart failure to check on their weight, be able to document that, if they had gained weight, you helped them to get in to see their physician. Then you could include in your report that you helped the patient avoid a potential admission.

Here are some examples of hard savings that can be documented:

• A case manager calls a patient with a chronic disease who says he isn’t feeling well and the case manager urges him to call the physician rather than waiting for the condition to get worse and ending up in the ED.

• A case manager coordinating care for an injured patient calls the physical therapist who expresses concern that the patient is experiencing extreme pain and isn’t making progress. She plans to include it in the report to the physician in two weeks.

• The case manager talks to the patient and suggests that he call the physician for an early appointment. The physician finds that the injury isn’t healing right. The case manager has prevented the member from re-injuring himself and can document this.