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Demonstrate your value to retain, add case management staff
Without data, administrators may have unrealistic expectations
With increasing scrutiny on medical necessity and cuts in reimbursement, along with a growing emphasis on care coordination and transitions in care, case management's position as a major player in the hospital should be assured. But that's not always the case.
"Some hospitals are eliminating case management positions as a cost-cutting measure, at a time when case management has never been more important," says Kathleen Miodonski, RN, BSN, CMAC, manager for The Camden Group, a national healthcare consulting firm with headquarters in Los Angeles. "Why this happens is ultimately due to the hospital leadership's lack of understanding of the value of case management in the revenue cycle and the role case managers have in supporting the organization's goals."
In many instances, case management leadership hasn't effectively marketed the department to the hospital's senior leadership, she says. "Even though case managers are doing a great job, nobody knows it. If senior management doesn't understand what case managers do, they may have unrealistic expectations of the department, or think that they can cut staff and save money," she says.
Miodonski cautions that case managers must keep in mind that, like everyone else in healthcare or other professions, they are not empirically entitled to their jobs. "In today's economic climate, people have to demonstrate their value to the organization every day. Case management leaders should make sure that the department leader to whom the department reports, understands what case managers do and their contribution. Otherwise, they can't defend the department when budget cutting time comes around," she says.
When Miodonski worked with a hospital where the case management department reported to the chief medical officer, she challenged him to shadow a case manager for a day to get an idea of what they do.
"It was a very eye-opening experience for him. He stopped after a couple of hours because he was exhausted. He told me he didn't know how the case managers get through the day," she says. That strategy won't work with every administrator who may not have time to follow a case manager. Instead, case management leaders need to look for other ways to educate the administration on the role of case managers and their contributions to the hospital.
Case management directors can't just go to the administration and ask for more staff, says Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, and partner and consultant in Dallas-based Case Management Concepts. They need to make a case for retaining staff or adding staff by showing the value that case managers bring to the organization. To demonstrate your value, track what you do every day, and create reports that demonstrate the impact case management has on the hospital's financial health, she says. (For tips on creating reports, see related article, below.)
You may need to explain the roles of your department before you make the case for more staff. In addition to giving the administration a list of roles, provide specific and detailed definitions and outline the functions your department performs for those roles, Cesta advises.
Miodonski points out that case managers help the hospital comply with payer requirements contracts, such as conducting pre-certification and continued stay reviews within a certain time span. They assist physicians in identifying the correct patient status and level of care. They have skills in writing appeals to capture revenue that otherwise would be lost, she says. "All of this prevents denials and keeps the revenue cycle moving," she says.
In addition to avoiding denials and moving patients through the continuum, case managers make significant contributions to the hospital's utilization review committee and in helping the hospital comply with accreditation and regulatory requirements, she says.
Miodonski advises that case management directors take every opportunity to present case management outcomes at meetings, particularly where other departments and senior leadership are involved, she says. "The responsibility of case management leadership is to help the hospital's senior leadership connect the dots from case management to the revenue cycle, regulatory and accreditation compliance," she says.
Case managers also should be aware of the kind of threats to the hospital's bottom line that the Medicare Recovery Auditor Contractor (RAC) reviews, and ever-changing payer regulations pose. Then they can use that information to demonstrate the impact that case managers have on preventing denials and ensuring that the documentation is in place for a successful appeal.
"Case management leaders should stay informed about healthcare reform and what the potential impact may be to the organization, and use that data to develop case management strategies to address the impact. Then they should be able to articulate case management's contribution to the senior leadership team, Miodonski says.
It's not uncommon for case management leaders to practice the same way for years and not take other issues, such as healthcare reform or the healthcare market into consideration.
"They need to be aware of what is going on, what new legislation and payer regulations are being proposed, and what the impact is likely to be, and plan accordingly," Miodonski says.
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Keep reports short and to the point
Gear data to your audience
When it comes to making a point with a hospital administrator or a physician, you have five seconds to get their attention and five minutes to keep it, says Gerri Birg, RN, MSN, managing director Huron Healthcare, a healthcare consulting firm with headquarters in Chicago.
This means that case management reports should be in a simple and concise format that busy administrators can understand very quickly, she says.
Beverly Cunningham, RN, MS, vice president, clinical performance improvement, Medical City Dallas Hospital, and partner and consultant in Case Management Concepts, Dallas, agrees: "Case management directors should present senior staff with succinct and relevant information. A presentation should be like sound bites — brief and to the point," she adds.
Birg advocates gearing your reports to the group to whom you are speaking. For instance, physician groups are more interested in patient outcomes. Health information management's major concern is compliance, and the chief financial officer's interest is revenue.
"The administration wants quality data but they want to see the financials as well. Too often they see case management as a place where the hospital is spending money rather than saving it," she says.
Cunningham adds that having a business plan for case management makes the difference between a department that succeeds and one that does not. Look at your hospital's goals and determine what case management contributes to meeting those goals, Cunningham suggests.
"Take a look at where the hospital is headed and show them what case managers can do to take them there. Case management directors should be creating a business plan every year that is aligned with the goals of the hospitals, Cunningham says.
If you don't know how to create a business plan, look for help from the strategic development office or the chief financial officer, she says.
Cunningham recommends that case management reports be related to the key indicators being measured by the hospital and should be aligned with the hospital's goals. For instance, length of stay may not be an issue, but maybe the emergency room frequently is on diversion. Showing that case managers have been able to free up beds and improve patient flow will be important to administration.
Or you can show how the case managers determined that some physicians are overusing ancillary services, which slows down the services for other patients and keeps them in the hospital longer, creating patient flow problems that lead to emergency department diversion.
Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, and partner and consultant in Case Management Concepts, LLC, recommends gearing your presentation to the issues that are most meaningful to your hospital administration.
"We use a case management report card when we talk to the administration but we are tracking much more than dollars these days because of all the changes brought about by healthcare reform. Quality is now attached to reimbursement so we have to demonstrate that as well," Cesta says.
When you start to develop your report, determine what measures can be used to demonstrate the effectiveness of case management. Categories of measures include process metrics, such as productivity and regulatory compliance, and clinical, financial, and service outcomes metrics.
Select quality metrics and financial metrics to track since case management impacts both. Whenever possible, include the dollar impact associated with the case management interventions, Cesta says.
Kathleen Miodonski, RN, BSN, CMAC, manager for The Camden Group, a national healthcare consulting firm with headquarters in Los Angeles says: "Participating in data gathering is the unglamorous part of case management but it's an absolutely essential role. It's time consuming to compile the information and develop reports but it's necessary in order present the information effectively," Miodonski says.
It's hard to describe what case managers do and many hospital administrators have only a vague idea, Miodonski points out. If you're not demonstrating value, you can't expect senior leadership to appreciate the job you're doing, and if you don't track case management metrics, you can't demonstrate value.
Document what case managers do each day and how much time it takes and present the information in a logical form. Have a group of case managers make a list of all the activities they do in a day and keep track of the time each takes. "The first thing leadership is going to ask is if you are working smart. Make sure there are no redundant processes in your department," she says.
Cesta recommends listing all the case management functions, and determining the time frames in which each role and set of functions must be performed. Then perform a time and motion study to measure case management productivity. Start by tallying the average number of reviews done each day by each staff member. Then determine the average length of time it takes to complete each review, Cesta suggests. "It is critical to keep an ongoing case management report card that demonstrates which areas of the organization are impacted by case management roles and functions, and provides a barometer of how the department and organization are doing," Cesta says.