Track your department’s interventions to prove your value to management

Five-person department calculates $1 million in savings

When Teresa C. Fugate, RN, BBA, CPHQ, CCM, developed the case management program for a hospital in which she worked, she included a provision promising that what the case managers saved by preventing extra days and avoiding denials would equal their salaries plus benefits.

"Within the first year we put job performance in the description, every employee in the case management department showed their worth to the organization by reducing delays in service and improving reimbursement equal to their salary plus benefits. In addition, we could calculate that their efforts paid for the operational budget and the director’s salary, plus benefits," says Fugate, now a manager for Pershing, Yoakley & Associates, a Knoxville, TN-based health care consulting firm.

After the case management performance tracking system was instituted, the hospital went through a period of layoffs. During that time, the case management department was the only department that increased staff.

"Not only did they do what the job standards asked for, they paid for the full department. We provided the savings through performance improvements and took it all the way to the board," Fugate says.

Last year, the case management department at that same hospital, Haywood Regional Medical Center in Clyde, NC, tabulated almost $1 million in cost savings related to case management interventions under the leadership of Shirley Trantham, RN, BSN, CCM, director of health resource services, which is the case management department at the 190-bed hospital. Fugate hired Trantham, who helped her develop most of the programs and took over the department when she left.

The department has five full-time equivalent case managers and two social workers.

The staff monitor case management interventions that prevent avoidable days and allow earlier discharges and put a dollar amount on them, using a case management database program created by the hospital.

With today’s emphasis on the increasing cost of health care, every hospital case management department must be able to show it is clinically and financially valuable, Fugate says.

"The clinical people want to see the clinical side of the equation. Physicians will be the case managers’ biggest proponents if they improve clinical indicators," Fugate says.

On the other hand, the administration wants to see the case management department’s effect on revenue. Tracking case management interventions is the best way to prove your worth, she adds.

Start by monitoring avoidable days, delays in services, and case management intervention and calculate the savings. Track your hospital’s denial rates and keep track of successful appeals.

For instance, make sure that laboratory reports and X-ray reports are on the chart when the physician gets to the hospital for rounds. If the report comes back after the physician leaves the hospital, it’s too late to discharge the patient that day. The case managers prevent an avoidable delay if they make sure the charts are there when the physician needs them, Fugate says. "If the case managers aren’t on top of this and aren’t working on those areas, the patients are going to stay longer."

If your hospital doesn’t provide cardiac catheterization on weekends, you could monitor the number of patients who need it on weekends and show the denials and the delays in services. Then the hospital can calculate whether the cost of opening the catheterization lab on weekends would be offset by a reduced denial rate.

"With avoidable days, hospitals can attach a dollar figure for Medicare and Medicaid patients," Fugate says. Any time a stay is more than the geometric length of stay, a hospital could lose $600 to $1,000 a day. "The more it costs . . . to provide the care, the less you’re making. Every day a patient stays because of delays in services costs the hospital money. If the case manager is intervening and can lower length of stay, the department can track how much the interventions save the hospital."

At Haywood Medical Center, the case management department generates monthly reports that show possibly avoidable days it has prevented and assigns each one to a department or unit in the hospital. If the X-rays are not back in time, a potentially avoidable day is assigned to the radiology department and shows that the case manager intervened and prevented a delay in care or discharge. If a patient missed a dose of Coumadin, it’s charged as a possibly avoidable day to nursing.

"These reports go monthly to each unit in the hospital and gives them a list of the things they need to improve on. We can’t take credit for all the savings. It’s a hospitalwide effort," Trantham says.

Recently, the case managers have noticed a number of delays in surgery due to OR restraints. "This tells the hospital administration that we need to consider if we need more surgeons or more operating rooms open," she says.

One way to monitor clinical outcomes is to benchmark your hospital’s performances against the Centers for Medicare & Medicaid Services (CMS) quality initiatives, Fugate suggests. "Hosp-itals are being asked to voluntarily publicize their data. The clinical outcomes are there." CMS is tracking hospital performance in the areas of heart attack, heart failure, and pneumonia. (For details, see box below, or go to:

"What is happening is that JCAHO [the Joint Commission on Accreditation of Healthcare Organizations] and CMS are coming together on the types of clinical and quality initiatives that hospitals should track," she says. The clinical performance measures were developed by CMS and JCAHO and endorsed by the National Quality Forum. The case managers should intervene to make sure the clinical indicators are met, Fugate says. For instance, left ventricle functions should be assessed prior to admission. If the case managers don’t see it on the chart, they should talk to the physician. The same is true of other indicators, she adds. "The case managers should be monitoring those indicators and intervening to make sure they are being done."

Documentation improvements is another area to track, Fugate adds. Improving documentation of medical necessity could be tracked by compiling the actual revenue changes in the coding. Keep in mind that your aim is not to increase the coding; it is training the physicians to code accurately.

A large portion of the case management savings at Haywood Regional Medical Center is generated by making sure that patients have the right admissions status, Trantham says.

"Doctors will admit patients for only 10 to 15 hours and list them as an inpatient admission. No insurance will cover this. Our case managers work with the doctors to get these patients admitted on observation status," she says.

The case managers at Haywood work closely with the social workers in getting patients discharged to nursing homes more quickly, sometimes by helping the physician see that the patient’s needs can be taken care of in another setting of care. One case manager recently coordinated care for a patient who had Medicaid pending and needed a wound vacuum at a cost of $70 a day just for the pump.

It was more cost-effective for the hospital to pay for the wound vacuum and release the patient, rather than keeping him in the hospital until Medicaid came through, Trantham says. "We try to be creative and still provide the patients with the care they need."