Outcomes track benefit of case management

CMs conduct monthly analyses

Case managers at Presbyterian Health Plan in Albuquerque, NM, conduct monthly cost-benefit analyses to help demonstrate the benefits of their interventions.

In 2001, the case managers were able to show a savings in health care utilization of $6.4 million.

The process is evolving, says Jean Calhoun, BSN, MSN, clinical director for case management at Presbyterian.

"We realize this is still a growing item for them. We’ve been doing it the past two years," Calhoun says.

Here are some examples of how the case managers determine savings generated by their interventions:

The case managers look at members who are frequently seen in the emergency department (ED) or have frequent admissions. They look at patients’ health care costs before they were referred to case management and for the first six months after the case managers began coordinating their care.

They can evaluate whether the patients continued with their patterns of frequent admissions or if the case managers were able to keep them out of the hospital or ED, and document the savings.

The case management department has been able to document how it can move members through the continuum of care to a more appropriate and less costly venue.

"For instance, in the past, there have been instances when a member might stay in the intensive care unit because nobody thought about moving them. If the member no longer meets the criteria, we get them moved and save the days there," Calhoun says.

When they call members to follow up on services, the case managers sometimes are able to direct the member to an appropriate level of care and avoid an ED visit and document the savings.

"I have called members who said they weren’t feeling well and were thinking about going to the emergency room. I have been able to help them get in to see their primary care provider instead. Avoiding an emergency room stay can generate great savings," says Paula Casey, BSN, MSN, senior clinical project coordinator for case management.

The case managers have been able to save money by negotiating rates with their out-of-plan providers.

For example, one case manager was able to save a lot of money on durable medical equipment by negotiating with the provider.