Approach helps CMs show their effectiveness

Set goals and measure your progress

By Michael Garrett, MS, CCM
Commissioner, Commission for Case Manager Certification (CCMC)
Rolling Meadows, IL

Case managers know that their services potentially can benefit their clients’ health, wellness, and autonomy. That impact, however, may not routinely be measured against specific performance indicators. Case management services can produce improvements in health care quality and cost-effectiveness. Those beneficial results, however, may not be systematically tracked and analyzed.

In other words, case managers may not be taking an outcomes-based approach to case management.

Whether they work for an insurance company, a third-party provider of services, or for an employer, case managers may see increased emphasis being placed on documenting, reporting, and improving case management outcomes. In addition, case managers may find that a systematic and well-defined outcomes-based approach is being advocated across the board in benefits programs, from group health to worker’s compensation benefit coverages.

While the focus on outcomes may be new to some case managers, the good news is this approach is very compatible with the practice of case management. Case management is, after all, a goal-oriented process.

Outcomes measures evaluate the results of interventions and performance (or, in some cases, nonperformance) of a function or process, which in this situation is case management. In health care, there are many variables that can affect the outcomes from case management, including:

  • disease process and severity;
  • process of care and treatment;
  • patient adherence and abilities;
  • competency, skills, and knowledge of the case manager;
  • benefit system.

All of these factors must be taken into consideration when developing and implementing appropriate outcomes measures in case management practice.

For example, early on in the case management process, the case manager develops a goal-oriented plan of care by working with the client/patient, family members, and the attending physician. The objective of the plan of care is to move the individual toward health, wellness, safety, adaptation, self-care, and/or rehabilitation. These goals provide the road map for how the plan of care is carried out, including timeframes, assigned responsibilities, and expected outcomes. The success of the case management process is measured by comparing the results to these goals.

In addition, the case manager provides a range of services during the case management process that impact outcomes, including:

  • establishing measurable case management goals that promote evaluation of the access, cost, and quality of the care provided;
  • identifying the achievement of goals, and differentiating the goals that result directly from case management interventions;
  • reporting quantifiable impact, including quality of care and/or quality of life improvements as measured against the case management goals;
  • recommending referral sources based on evaluation of the provider’s quality of care and ability to meet the needs of the individual;
  • maximizing client outcomes through incorporating community-based and other services that are outside the benefit plan, whenever possible.

Outcomes in case management generally can be divided into three categories:

— financial or economic, focusing on cost savings and return on investment, or ROI;

— patient/client satisfaction, based on feedback from individuals and family members receiving services;

— clinical/functional, looking at the patient’s functionality in life, such as the ability to return to work or ability to live independently, depending on the benefit coverage.

These outcomes may be viewed as standalone results or as part of an overall assessment of the effectiveness of case management services. An employer, insurance carrier, or other referral source may place greater emphasis on one outcome over another, based upon its priorities and needs. For the purpose of this article, the outcomes will be discussed separately.

Financial outcomes relate primarily to cost savings from case management services in both workers’ compensation and group health. These savings can be achieved in several ways. For example, case managers can contribute to cost savings by eliminating duplicate services and avoiding unnecessary services through timely and appropriate coordination and communication. Case managers also may direct or channel patients to preferred providers/vendors, such as centers of excellence with pre-established reimbursement rates that result in savings to the benefit plan. Typically, case managers report on the cost savings (both gross and net) as well as the ROI, which is calculated by dividing the gross savings by the cost of the case management services.

Patient/client satisfaction gauges the experience of individuals and family members receiving services. This may be accomplished through surveys or other standardized tools, or through grievance mechanisms that collect feedback from those who are unhappy with services received. Increasingly, employers want to ensure that their employees and their dependents have a good experience with the benefits and services provided by case managers. A positive experience can help reinforce the message that the employer cares for the health and well being of its employees and their families.

Clinical/functional outcomes can be measured by a number of different means. For example, in worker’s compensation, this may be based on the success of a rehabilitation plan and whether or not the individual eventually was deemed employable and/or returned to his or her job. In group health, clinical/functional outcomes may relate to medical improvement, such as stabilizing the person’s condition or returning the individual to his or her previous state of health.

Outcomes are very important to tracking the attainment of case management goals, including when milestones are reached and challenges or obstacles remain. Case managers, however, must be very clear about what their outcomes are based upon, particularly when reporting back to an employer, insurance company, or another involved third party. For example, if financial outcomes are being tracked, the case manager must specify what costs and/or avoided expenses are included in the analysis. There also needs to be an explanation of how the savings are calculated. In terms of patient satisfaction, how the information was gathered must be explained, and the tools that are used must be described. Because there is no widely recognized standard for determining and analyzing these outcomes, clarifying the criteria is just as important as reporting the final results.

Using outcomes to evaluate the impact of case management will help to quantify the process for all involved, from the client receiving the services to the employer and the insurance company. As a case manager, embracing an outcomes approach demonstrates a commitment to providing the best possible care for the patient, while taking into consideration the needs and priorities of all related parties.

[Michael Garrett, MS, CCM, is a commissioner for the CCMC, which is the first and largest certifying body for case management professionals to be accredited by the National Commission for Certifying Agencies. URAC has determined that the CCM credential is a recognized case management certification. Garrett also is vice president of business development for Qualis Health of Seattle, a private, nonprofit health care quality improvement organization that offers programs and services to improve the quality of health care delivery and health outcomes for individuals and populations.

For more information or to obtain an application for the CCM, contact the CCMC at (847) 818-0292 or visit the CCMC web site at]