8/6/2019 10 Questions to Optimize Case Management Performance

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8/6/2019 10 Questions to Optimize Case Management Performance

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Its no secret that increasing regulatory demands and ever-shrinking reimbursementsare putting pressure on todays healthcare organizations. The result is that many providers are trying to do more with less, leading to breakdowns in efficiency that eat away at revenue and degrade quality of care. Its time to ask some toughquestions to ensure your case management function is positioned to sustainclinical excellence and a healthy bottom line.

1. Would reducing length of stay improve your bottom line?For most healthcare organizations, even a slight reduction in length of stay (LOS)represents significant savings. Case in point: a 1,000-bed, three-hospital systemhad numerous staffing and process-related issues that contributed to an increasedLOS. Their interim director implemented productive communication, effectiveeducation and clearly defined accountability, as well as a team-based staffing model.LOS subsequently declined from 6.5 to 5.2 days generating $6 million in additionalrevenue and nearly $2 million in cost savings.

2. What are your performance standards?Performance standards ensure accountability and give staff a goal to work toward. To design standards that positively impact the case managementprocess, youll need to start with a clear picture of current performance. First,evaluate your process for managing progression of the patients plan of care,compiling metrics that measure performance in key areas. Then, comparethese metrics to internal benchmarks and predetermined industry standards.Improving this process will produce results that are greater than the investment.

3. Does your medical staff support these standards?For performance standards to enable success, medical staff support is essential.Gaining the medical staffs support will require communication, not only of thestandards, but also the rationale and data (such as literature) that underlie them.Further, physicians may benefit from effective education which includes articulationof the benefits to their patients and the action plan to achieve them. Finally,periodic updates on progress and outcomes will reinforce the collective efforts.

4. How do members of the interdisciplinary team work together to manage LOS?Case management services are most effective if the interdisciplinary team workstogether to keep the patients plan of care active. Establish an integrated, patient-centric interdisciplinary team in which everyone understands his or her roleand how to interface with the rest of the team. Institute processes that facilitatecare integration, and hold each team member accountable for timely executionof components of care to keep LOS on target. Refer delays in treatment anddischarge to physician leadership, who will work with the patients doctor toresolve issues.

5. Do you have a gate-keeping process to determine accurate admission status? An effective gate-keeping process ensures the patient receives the correct levelof care and admission status upon arrival and documentation supports medical

10 Questions to Optimize CaseManagement PerformanceBy Bobbi Baguhn, MA, BSN, RN, CNLC, CMAC

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8/6/2019 10 Questions to Optimize Case Management Performance

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necessity. Designate a seasoned case manager who will work with the physicianadvisor to evaluate clinical criteria for each case and determine an accuratestatus. The result will be satisfied patients (and their families) who receive theappropriate care from the start and fewer denials and wasted resources.

6. Is your observation services rate increasing?Observation services rates are increasing for many healthcare providers. Theresult is eroded revenue because observation services are reimbursed at lowerrates than inpatient admissions. Its also frustrating for the patient, since theirco-pays and out-of-pocket deductibles are higher for observation than for aninpatient stay. When clinical criteria are reassessed, it is frequently the case thatsome of these patients should have been admitted as inpatients. This upwardtrend in observation services rates clearly illustrates the need for an experiencedcase manager to determine an accurate admission status for each patient.

7. Are you controlling costs by reducing resources or by improving efficiencies? With the implementation of MS-DRG (Medicare Severity-Diagnosis Related Groups)in 2008, many organizations are experiencing a decline in reimbursement. Itstempting to compensate by cutting personnel and reducing costs in other criticalareas. A better strategy is to become more efficient, consume fewer resources andlower the cost per case. An integrated approach to case management is one way toachieve this, with the ultimate benefits of improved care and fiscal performance.

8. Do you provide case management services seven days a week?Having case managers on task seven days a week means patients dont remainin the hospital over the weekend unnecessarily. This one simple action can have

a significant positive impact on your bottom line by reducing LOS, decreasingexposure to hospital-acquired conditions, and enhancing throughput.

9. What about the consequences of readmission for hospital-acquired conditions?Healthcare reform legislation ties reimbursement to hospital readmission rates, withreduced payments for organizations experiencing a higher rate of readmission andincentives for those that excel. Not all readmissions can be prevented. However,effective case management keeps it in check. In the future, case managers may follow patients throughout the entire continuum of care requiring healthcare organizationsto partner with physician practices, home health agencies, nursing homes and otherproviders to identify high risk patients and manage cases outside the hospital.

10. Is there a strategy for partnering with physicians for possible bundled payments?Bundled payments present a financial incentive for physicians to become more involvedin the hospitals plan of care for the patient. For example, if the inpatient payment for anormal LOS is $4,000, Medicare reimburses the hospital that amount, even if the patientis hospitalized for a longer period. Under a bundled payment system, physicians will bereimbursed the same way. Since bundled payments will likely represent significantsavings for Medicare, most analysts expect it to become reality in the near future.

Whats next?If youre struggling with case management issues that are affecting profitability, askingthese 10 questions will help you focus and anticipate changes on the horizon. Nomatter where your organizations case management capability stands today, help isavailable to ensure youre positioned to handle the complex challenges that lie ahead.

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