Taking care of patients also means taking care of business

Balance patient advocacy with the financial side of care

If your case management department isn't involved in the business side of health care, you're missing opportunities to affect your hospital's bottom line and to ensure that your patients get the most effective, cost-efficient care.

The balancing act that case managers maintain between being a patient advocate and looking out for the hospital's best interests makes being involved in the business side of case management imperative, says Toni Cesta, RN, PhD, FAAN, vice president, patient flow optimization for the North Shore-Long Island Jewish Health System.

"Case management is all about the patient. Ensuring that your patients receive appropriate, timely, and cost-effective care is more than just a business case for the hospital. It's also a value-added benefit for patients," adds Beverly Cunningham, RN, MS, vice president, clinical performance improvement, Medical City Dallas Hospital.

Stop snowball effect before it starts

Keeping patients in the hospital extra days and giving them unnecessary treatment can have a snowball effect, she points out. When an inappropriate patient takes up a bed, patients may stay in the emergency department longer because no beds are available, and the emergency department may have to go on diversion, Cesta adds.

The patient in turn is exposed to potential infections, and to top it off, the hospital doesn't get paid for the stay.

"From a standpoint of quality, patient safety, and patient satisfaction, as well as the bottom line, this is totally a losing situation," she says.

Patients also can suffer financially if they stay in the hospital extra days when they could have been discharged. They could use up their Medicare lifetime reserve days and lose their resources for the future. Most patients, whether they have commercial insurance or are covered by a government plan, have a financial limit or a benefit allowance and many will have to pay a percentage of the hospital charges.

"When you keep a patient on an IV longer than necessary or they have more than the recommended number of X-rays, there's no value added for the patient and it becomes a patient safety issue as well as a financial issue for the patient," Cunningham says.

These examples illustrate how case managers have an impact on every component of the organization, from patient care to the hospital's bottom line. But many organizations don't understand the value that case management brings to the table, Cesta adds.

Value of case managers

"Whether it's denial management, length of stay, throughput, or quality of care, the impact that an individual case manager can make can be measured but we don't always measure our impact appropriately. Proving our value is our challenge," she says.

Case management directors and managers should develop strategic planning initiatives, by analyzing what has happened in the past year and planning for the next, she suggests.

For instance, if the case management department needs more staff, the director has to convince administration to approve and fund it by presenting the business case, Cunningham points out. Start by identifying some meaningful key measures for your hospital. Do a comprehensive analysis and look for trends to report, she advises.

Make sure that your key indicators mesh with the issues your organization is focused on and match the organizational goal, she adds.

"If you're going down one road and the organization is going down a different road, it's not helpful," she adds. Watch your trends, year over year and quarter over quarter, and benchmark whenever possible, Cunningham suggests.

For instance, with Medicare patients you can look at the gap between the geometric mean length of stay and your actual length of stay or look at severity-adjusted data if available.

Benchmark apples to apples

"It's hard to tell in your own organization when your costs are too high if you're not benchmarking, but you have to benchmark using apples to apples," she adds.

In order to make valid comparisons, you must use severity-adjusted data; otherwise, you're not allowing for spending more on one patient than another if one is more severely ill, Cesta says.

Data from the new MS-DRG system will be helpful for hospitals that don't have severity-adjusted data because the system addresses the severity of a patient's condition, she adds.

Analyze the impact of case management on individual patients and groups of patients, including resource utilization and how resource utilization and cost affect the bottom line of the organization, Cesta suggests.

"Case managers can make a case for retaining staff or adding staff by showing the value that case management brings to the organization. We need to show the relationship between how the work is deployed and how staff intervene to optimize resources on a case-by-case basis," she adds.

Case managers are in a position to collect and analyze data that can affect many aspects of the health care system including: physician practice patterns; ancillary department services, such as housekeeping and radiology; denials; and patient flow, she points out. For instance, the hospital may lose a lot of money on pneumonia or congestive heart failure because of the length of stay or the costs are too high.

The case management department and individual case managers can analyze care delivery components for these patients and determine where changes could be made. Start by looking at the key direct care resources that need to be delivered for patients in the DRG you are targeting and analyze what resources they are receiving. If you don't have other data available to you, you can figure out in aggregate the average cost of taking care of patients with a particular diagnosis by tabulating how many X-rays the patients have, the cost of antibiotics, and other costs of care, Cesta says.

Outline cost of care for particular patients

"This gives case managers a general idea of the cost of care for that particular type of patient and when there are outliers you can determine the reason, such as the antibiotic choice by a particular physician or one physician's practice of ordering additional X-rays," she adds.

Use evidence-based literature to determine the standards of care for a particular diagnosis. For instance, if pneumonia patients routinely receive multiple chest X-rays or MRIs or CT scans, determine if this is necessary.

"It slows down patient flow, prolongs the stay, and increases the costs if the hospital is over-treating patients with X-rays and antibiotics," Cesta says.

Look at the length of stay and cost per case and analyze in depth what contributed to both, such as the number of labs, the number of X-rays, or the number of physical therapy evaluations.

At her hospital, Cunningham analyzes cost-of-care data comparing the hospitalist group and the internal medicine physicians to determine the outliers.

"We look at the practice patterns of the outliers and compare them to evidence-based practices, using the evidence as the benchmark," she says. For instance, if a physician is ordering physical therapy for a particular group of patients and the literature doesn't recommend it, the team points it out to that physician.

Combining standards of care and benchmarking is the best way to determine if patients are receiving the best and most cost-effective care, Cunningham asserts. "Evidence-based care doesn't always happen. The whole idea behind critical pathways and practice guidelines is they reduce variation and improve the quality and cost of care," Cunningham says.

Make your data work

Share your data with other departments and collaborate with them to improve processes and make the case for adding staff, lengthening hours of coverage, or purchasing equipment for the department, such as laptops or software, Cesta suggests.

"Case management collects so much data that could benefit the rest of the organization but we don't always share it in a meaningful way so that the other departments see us as a valuable asset instead of a problem. We can collaborate with them to improve patient flow and services as opposed to finger-pointing," Cesta says. For instance, you may determine that there are delays in the cardiac catheterization lab on Mondays because it isn't open on Sunday.

In another example, when Cesta determined that physical therapy consultations were creating delays at one hospital, she shared the data with the physical therapy director.

"I was able to show her all the delays associated with the physical therapy department. It wasn't because the physical therapists weren't doing a good job. It was because there weren't enough of them. My data helped the director of physical therapy make the business case for more staff by showing administration all the extra days we were experiencing because the physical therapists couldn't meet the need," Cesta says.

After you have tracked trends and analyzed data, spend time deciding how you are going to present the data to administration, Cunningham says. "What you take to administration has to be in a format they can understand and that relates to the key indicators measured by that hospital," she says.

• Present concise, clear, and simple data that a busy administrator can understand very quickly, Cunningham suggests.

"It should be like sound bytes. Senior staff need succinct and intuitively obvious information," she adds.

• Make sure you present information that is important to them.

"At my hospital, bed days are something we budget on, but if I take denials data to the CFO, that means more to him than length of stay," says Cunningham.

Putting a dollar amount on the data makes them much more meaningful, Cesta adds.

"If your data show how case management has affected avoidable days or denials, show the financial impact. If you're making the business case for more staff, dollars will be very powerful," Cesta says.

• Gear your presentation to the issues that are most meaningful to your hospital administration.

For instance, length of stay may not be an issue but perhaps the emergency department frequently is on diversion. Show that case managers have been able to free up beds, improving patient flow, and that 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.

Be aware that in spite of your best efforts, you may not get what you are seeking, Cunningham cautions.

"Case management directors must realize that just because they present the data and present them well, they might not get the staff they need. More and more case management directors tell me that unfunded patients are having such an impact that their hospitals are cutting staff," she says.

(Editor's note: For more information, contact Toni Cesta, RN, PhD, FAAN, vice president, patient flow optimization for the North Shore-Long Island Jewish Health System, e-mail: tcesta@lij.edu; Beverly Cunningham, RN, MS, vice president, clinical performance improvement, Medical City Dallas Hospital, e-mail: Beverly.Cunningham@hcahealthcare.com.)