How to measure the value of case management

Process, financial, satisfaction measures crucial

By Patrice Spath, ART

Brown-Spath & Associates

Forest Grove, OR

In today’s health care environment, all programs must prove their value to the organization and its patients. Hospital case management programs are no different. Case managers are being asked to substantiate the positive impact of their services in three areas: clinical outcomes, financial benefits, and customer satisfaction. Because case managers are part of the health care team, it is sometimes difficult to distinguish their unique contribution to the patient care experience. It is even harder to quantify this contribution.

The value of a case management program can be evaluated from two perspectives: tangible benefits and intangible benefits. Tangible benefits may include:

• reduction in service cycle time through more coordinated scheduling;

• reduction in quality defects (known as "rework" in manufacturing) with its attendant readmissions, prolonged length of stay, repeat surgery, and other costs of correction;

• improvement in the clinician’s ability to make choices concerning interventions based on cost-effectiveness and cost utility information provided by the case manager;

• improvement in management’s ability to assess the causes of adverse outcomes and inefficient processes and the degree to which treatments, devices, procedures, and interventions are comparatively effective;

• elimination of health care delivery service redundancies by improving labor efficiency through enhanced information at the point of care;

• reduction in the use of more expensive interventions to achieve the same expected outcome;

• redesign of inefficient processes to optimize personnel, space, and materials;

• enhancement of clinical quality through continuous management of process variation, feedback, group process, ownership, and delivery system coordination;

• workplace harmony and professional satisfaction through better communication and collaboration, which result in less personnel and professional turnover.

Intangible benefits may include:

• improvement in accuracy of bid proposals for managed care contracts through more accurate assessments of the cost of providing services;

• improvement in reporting of credible outcome data;

• improvement in patient and provider service and satisfaction, leading to new and retained customers and contracts;

• flexibility in the design of patient services to encompass customer demands.

To measure the impact of their services effectively, case managers must start with a clear understanding of the needs of all stakeholders. What are the physicians’ expectations? the bedside nurses’ expectations? the financial officer’s expectations? and so forth. Once the stakeholders’ expectations are clear, case management performance measures can be defined to determine whether or not expectations are being met.

Two types of measures should be used by the case management department to determine if their services are valuable to stakeholders: process measures and outcome measures. Process measures can be used to evaluate rework, compliance with departmental standards, productivity, services delivered, service cycle time, and budget variances. It may be argued that case management processes are merely the means for achieving results, and performance measures should focus on outcomes, not work tasks. However, without the collection of data about case management tasks that stakeholders view as important, it’s not possible to determine if these customers’ expectations are being met. It is important, however, to limit measurement to those processes considered to be significant. Otherwise, you’ll end up with lots of unimportant data.

Some case management departments measure patients’ clinical outcomes to judge the effectiveness of case manager interventions. It is idealistic, however, to assume good clinical outcomes are directly related to the work of the case manager alone. A direct causal relationship between case management interventions and patient outcomes — for example, improved functional status — has not been well-established. Out comes can be influenced by many factors, including the patient, the environment, the doctor, and the disease process itself. Until a linkage between specific patient outcomes and case management interventions can be clearly demonstrated through scientific research, it may be best to use surrogate measures. Surro gate measures are used to evaluate case management tasks that are presumed to partially influence patient outcome results.

For example, if early social work intervention is thought to be a critical factor in reducing social complications following the patient’s discharge, the following surrogate process measure could be used: Percentage of patients receiving their first social work service within 24 hours of hospital admission.

Financial outcomes have traditionally been used to measure the effectiveness of case management service. Financial outcome measures assess indicators such as:

• costs associated with health care delivery and services;

• utilization of diagnostic tests and procedures;

• days of discharge delay;

• average length of hospital stay;

• hospital readmission rates.

Just like clinical patient outcomes, the factors that influence financial results are very complex. It is unlikely that case management interventions can be given full credit for reducing hospital and continuum of care costs. Factors such as new treatment modalities, increased patient education, increased number of out-of-hospital treatment alternatives, evidence-based practice guidelines, disease management, and so on have all had an impact on reducing total health care expenditures. It may be best to develop surrogate measures of case management tasks that are presumed to partially influence financial outcomes. For example, if preadmission discharge planning is felt to be a critical factor in reducing the number of unnecessary postoperative days of care, the following surrogate case management measure could be used: Percentage of elective surgery patients who receive preadmission discharge planning.

Evaluating stakeholders’ satisfaction with case management services is important. Targeted survey tools can be used to judge patients’ satisfaction with various aspects of case management services, such as:

• adequacy of discharge plan explanations;

• level of involvement of patients/families in decision making;

• timeliness of response to case management-related questions and problems.

Other customers of the case management department (physicians, nurses, referral and contract providers, and so on) also can be surveyed to determine their level of satisfaction with relevant case management services. Accompanying this article is a survey instrument that could be used to gather case management satisfaction data from home health agencies. (See survey instrument, p. 30.)

To prove the value of case management programs, case managers must be able to demonstrate that case management interventions are effective and accomplish their goals. Gather data to show the stakeholders that case management reduces future problems — for example, rehospitalizations, overuse of services, miscommunications between caregivers, and so on — and significantly improves patient and provider satisfaction.

Remember that measurement is not an end in itself, but a tool for more effective management. Performance measures by themselves will produce few benefits. Better case management performance can only come from improving the processes. Use the results of your performance measurement system to effect positive change in case management systems and processes to ensure that case managers continue to add value to the patient care experience.

Editor’s note: Patrice Spath has written a new 135-page book titled How to Measure and Improve Case Management Performance, published by Brown-Spath and Associates. Cost: $35. To order, call (503) 357-9185, or order on the Internet at www. brownspath.com.