Justifying case managers pays off for hospital

Statistics show how CM affects the bottom line

When the Floyd Rehabilitation Center in Rome, GA, hired its first case manager four years ago, the hospital administrator told Karen Sablon, director of case management, to create the position if she thought it was needed.

Now, in these lean times, when every position has to be justified, Sablon is ready to show the financial types just what case management can do for a hospital's bottom line.

"A lot of people in the past have said case management isn't revenue-generating. But it allows the clinical staff to do what they are supposed to do and increase productivity," Sablon says.

For instance, when the center added a pediatric case manager, the productivity of the therapists increased 12% in the first six months, she says.

"They had more time to treat patients because they didn't have to deal with insurance people," she adds.

At Floyd, all members of the case management department also function in a marketing role, and Sablon tracks increases in referrals to show it is paying off. (For details on marketing by case management, see related article on p. 82.)

The rehab center is part of Floyd Medical Center, which includes a 304-bed acute care hospital with an inpatient rehab component, outpatient rehab, a community respiratory care center, a home health agency, a durable medical equipment agency, a hospital, a primary care physician group, and the new occupational health program.

Tracking data to prove productivity

To justify the day hospital case manager, Sablon is tracking the average daily census as well as growth for the outpatient program among patients who were in the day hospital. She projected that a case manager would help maintain an average daily census of five patients, and that the outpatient population would grow. She's compiled monthly records that back up her assertion.

"We're still not revenue-producing, but we are showing that we have productivity and that we're affecting the bottom line," she says.

With the new occupational health center that opened late last year, Sablon is working to show what case management can bring to the organization financially.

"As time has gone by, the hospital administration is asking for data to show how case mangers will contribute. A lot of it has to do with reimbursement. What we could get three or four years ago, we can't get today. Now we have to justify every new position and show how it can add value to the organization," she says.

To justify the case manager for occupational health, Sablon plans to show the hospital administration how a case manager can help keep patients in the Floyd Medical Center system.

"If a person comes to our emergency room after being injured on the job, then is sent to a specialist who refers him to another facility for lab work, we're losing this patient," she points out.

She is compiling statistics on workers' compensation case costs and comparing them to patients that came through the hospital who were not case-managed.

"We can show that the average patient costs a certain amount and we didn't generate that much because the patient didn't stay in our system. Case management can help us keep that patient," she adds.

Admissions coordinators handle insurance

Floyd employs two RNs as two admissions coordinators for inpatient rehab. These admissions coordinators screen the patients who are referred to the center and handle the insurance negotiations that have to be done on an individual basis.

Sablon is expanding the role of the admission coordinators so when they screen a patient who is not appropriate for inpatient rehab, they can recommend the patient be referred to another part of the continuum, such as the day hospital or home health.

There are two case managers on the inpatient program who are social workers. They handle case management along with the counseling, psychosocial, and discharge planning process. The case managers work closely with the families, determine what the patient will need after discharge, and follow through with the insurance companies as needed.

There are separate case managers for the pediatric outpatient program, the day hospital, the outpatient center, and the new occupational health component.

When a patient comes in for his or her first appointment in pediatric or outpatient adult services, the case manager meets with the patient, discusses patient rights and responsibilities, reviews hospital policies for cancellations, and gives the patient her phone number.

"If a patient has a question or a problem, they can talk to the case manager. When patients know only the therapist, they may have a hard time getting them on the telephone because the therapist is treating patients. Often the case manager can solve the problem on the spot," she says.

The outpatient case mangers have a caseload of 25 to 30 patients, in addition to taking in new referrals, scheduling first-time evaluations, and greeting new patients. On the inpatient side, the case managers handle 14 or 15 patients at a time. In addition to traditional case management duties, they also do psychosocial counseling and family counseling.

Sablon also plans to coordinate case management with the hospital's home care services and hospice so patients will receive coordinated care throughout the continuum.

When the rehab center opened in 1974, the admissions information was sent to the nursing unit and the nurses had to get the data from the referring facility or physician, get approval for treatment, and act as a liaison with payers.

"It can take hours to verify a patient's benefits and get approval. This took a lot of the nurses' time and affected their productivity," Sablon says.

Case managers take care of scheduling

Before the pediatric case manager was hired, it was up to the therapists to schedule pediatric patients for their first evaluation. Often there was a long lapse between referral and evaluation because the therapists were trying to schedule appointments in between their other duties.

"Now that case management is doing it, the therapists have less downtime and patients don't have to wait as long to get in. Case management schedules the patients while the therapists are treating other patients," Sablon says.

At the time the rehab unit opened, the assessment tool for getting patients approved for the program was only one page long. Now, it's grown to four pages because of payers' demands for more justification, Sablon says.

"We got denials because insurers said we didn't give them a clear enough picture. In the past four years, we've redone our assessment tool twice to give them the clear picture they need," she says.