Case managers can lead the way in P4P initiatives

Start by identifying your top DRGs

Case managers will be invaluable to their hospitals if the Centers for Medicare & Medicaid Services (CMS) institutes pay-for-performance measures for all hospitals, Teresa Fugate, RN, BBA, CPHQ, CCM, asserts.

"Case managers are so important in this effort because they are in there conducting concurrent review based on standards of care. Their bottom line is to merge the clinical and financial and understand how improvement in quality of care can impact reimbursement," says Fugate, manager with Pershing, Yoakley & Associates, a Knoxville, TN-based health care consulting firm.

The key in hospitals is to start by identifying your top DRGs. Most are likely to be related to CMS indicators, she adds.

Fugate recommends that hospitals start concentrating on the CMS indicators. Instead of collecting the data retrospectively, they should be monitoring them concurrently. "If you collect data only retrospectively, you have lost the ability to intervene and affect the outcomes," she says.

"It’s important to align case management, performance improvement activities, and quality improvement activities," Fugate explains.

Incorporate the quality measures for the targeted DRGs in your case management activities. Make sure the interventions occur in a timely fashion. If it doesn’t happen, intervene with the physicians and get them to document why they didn’t do it.

"If you are doing only retrospective data collection, you’ve missed an opportunity to intervene and improve patient care," she says.

Hospitals should enlist a physician champion who will help them proactively assess their clinical practices. They should verify data collection and accuracy.

"Many times, data collection is not accurate, which sets the hospital up for failure," she says.

The hospital should assemble the appropriate teams to address the issue and make every clinical person aware of what is going on.

People involved should include physicians, nurses, ancillary services, case managers, and health information management.

In the late 1990s, Fugate worked with a hospital system to develop performance improvement initiatives for patients with pneumonia and congestive heart failure.

The team developed physician-driven protocols and used them to develop multidisciplinary pathways that included the most important pieces of information and processes to ensure that patients got the proper care in a timely and efficient manner.

"We worked on standardizing processes and creating care coordination across the organization, not just involving case managers, but a broader look to improve quality of care with the case manager overseeing the process," Fugate says.

She trained the staff to work with other disciplines that are part of the process and to build relationships. "We break down the silo effect, the attitude that It’s not my job,’" she says.

The pathways included specific patient education for each diagnosis and identified the top goals for that patient. For instance, goals for congestive heart failure patients included smoking cessation; monitoring signs and symptoms of illness, such as weight gain; and reducing sodium intake. The goals were either on the patient chart or posted in the room. Everyone on the staff who went into the room was responsible for discussing the goals with the patients.

"Patients remember only 10% to 20% of what you tell them. If you tell them one time, they’re not going to remember it. You have to go over and over it," Fugate notes.

Case managers should conduct daily oversight of individual patient plans of care and work with the physicians to ensure the recommended guidelines are met.

For instance, a recent survey by the American Health Quality Association showed that 31% of patients considered ideal candidates for ACE inhibitors were discharged without a prescription. This is a prime example of an area where case management intervention can improve outcomes, she adds.