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Is your average length o stay increasing? Per-

haps youve seen a higher readmission rate,

or an upward tick in denials. Or maybe youre

experiencing throughput issues, with patients

waiting in the emergency department or beds

that are ull due to slow discharge and other un-

necessary delays.

Youre not alone. In an era o increasing regu-latory demands and ever-shrinking reimburse-

ments, many providers are trying to do more with

lessleading to breakdowns in eciency that eat

away at revenue and degrade quality o care.

Fortunately, theres a solution: a highly inte-

grated approach to case management is critical

to maintaining clinical excellence and a healthy

bottom line. Te ollowing strategies or improv-

ing case management services can help you put

your organization back on track.

Bobbi Baguhn is a case

management consultant and

interim healthcare leader with

B. E. Smith in Lenexa, KN.comStocK/comStocK/thNKStocK

1.Conduct an assessment o case man-

agement services and establish peror-

mance standards.

he irst step is to accurately assess your organi-

zations process or managing progression o thepatients plan o care, compiling metrics measur-

ing perormance in key areas. hen, compare the

metrics to internal acility benchmarks and prede-

termined industry standards, such as Medicares

national standard or geometric mean length o stay

(GMLOS); readmission, complication and observa-

tion rates; risk and severity adjusted data; and pro-

ductivity standards. Once you have a clear picture o

how your organization is perorming, establish per-

ormance expectations to improve problem areas.

I your organization doesnt have the capabil-

ity in-house to design and perorm an assess-ment, external assistance is available. Improving

this process is worth the initial investment, when

you consider how much even a 0.5 day reduction

in LOS would add to the bottom line.

2.Partner with medical sta to ensure

perormance standards are met.

Gaining the medical stas support or

perormance standards is critical to appropri-

ate progression o patient care. When an orga-

nization is operating proitably and in a highly

ecient manner, its physicians will benet and

will be empowered to ocus on providing out-

standing care. o gain their acceptance and part-

nership, provide education on these benets, in-

cluding valid data illustrating the positive impact

o reduced LOS on both nancial perormance

and quality o care.

3.Ensure members o the interdisciplinaryteam work together to eliminate delaysand meet the organizations target LOS.Your acilitys case management services wont

be eective i the interdisciplinary team per-

orms their tasks in a silo. Its crucial that theentire team knows the patients plan o care and

works together to keep it moving along. o meet

this goal, establish an integrated, patient-centric

interdisciplinary team in which all staf members

understand their roles and how to interace with

the rest o the team to ensure optimum progres-

sion o care. Support the team with clearly de-

ned processes to acilitate care integration, and

develop a system in which each team member is

held accountable or ensuring the care com-

case management

increasingprofitability

8 Strategies forBest-in-ClassCase ManagementIn an era o increasing regulatory demands and

shrinking reimbursements, providers are trying to domore with less, leading to breakdowns in efciency.Whats the solution? By Bobbi Baguhn, MA, BSN, RN, CNLC, CMAC

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ponents are executed in a timely manner to keep LOS on target.

Reer any delays in treatment and discharge to physician leader-

ship, who will work with the patients doctor to resolve issues.

4.Implement a gate-keeping process to ensure accurateadmission status.When a patient is assigned an incorrect admission status,it causes numerous problemsnot the least o which is an inap-

propriate level o care, which rustrates patients and consumes

valuable resources. Additionally, many healthcare organizations

are seeing an increase in observation services rates, which are re-

imbursed at a lower level than inpatient rates. When clinical crite-ria are reassessed, it becomes clear some o these patients should

have been admitted as inpatients.

A hallmark o efective case management is an established gate-

keeping process to ensure documentation supports medical ne-

cessity and the patient is assigned the correct admission status

upon arrival. Designate a seasoned case manager who will work

with the physician adviser to evaluate clinical criteria or each case

and determine an accurate status. Te result will be satised pa-

tients who receive an appropriate level o care rom the startand

ewer denials and wasted resources.

5.I your organization is experiencing reduced Medicare/

Medicaid reimbursements, improve eiciencies to

make up the dierence.

In 2008, Medicare implemented MS-DRG (Medicare Severity-Di-

agnosis Related Groups), which determined payment amount by

diagnosis severity. In short, healthcare organizations now are paid

more or treating sicker patients. MS-DRG also was the rst time the

industry saw reimbursement based on quality o care, with Medicare

reusing to pay or numerous hospital-acquired conditions.

Organizations experiencing a drop in reimbursement are now

in the process o budgeting to provide the same care with less. Its

tempting to cut payroll and reduce costs in other critical areas to

compensate, but a more eective strategy would be to enhance

the bottom line by becoming more ecient and consuming ewerresources. An integrated approach to case management is one way

to get there.

6.Provide case management services every day, not juston weekdays.Having case managers on task seven days a week meanspatients dont remain in the hospital over the weekend unneces-

sarily. Tis one simple action can have a tremendous impact on the

organizations bottom line by reducing LOS, decreasing exposure

to hospital-acquired conditions and enhancing throughput.

7.Prepare or the fnancial consequences o readmissionor hospital-acquired conditions.Its commonly known that a patients length o stay directlycorrelates with the likelihood o contracting a hospital-acquired

condition requiring readmission. Research indicates readmis-

sion is a signiicant issue. A recent study reported nearly one in

ve Medicare patients discharged rom the hospital is readmitted

within 30 days [Jencks SF, Williams MV, Coleman EA. Rehospital-

izations among Patients in the Medicare Fee-or-Service Program

N Engl J Med 2009; 360:1418-1428 April 2, 2009].

Recent healthcare reorm legislation includes incentives and pen-

alties tied to hospital readmission rates. Organizations experiencinga higher rate o readmission will see their reimbursements reduced

while those excelling will be incentivized or their perormance.

While not all readmissions can be prevented, efective case

management is critical to keeping it in check. In the uture,

we may see transitional case managers who ollow patients

throughout the entire continuum o care. his will require

healthcare organizations to partner with physician practices,

home health agencies, nursing homes and other providers to

identiy high risk patients and perorm case management out-

side the hospital.

8.Develop a strategy or partnering with physicians ibundled payments are implemented.Several hospitals currently are testing a system in whichMedicare payments to physicians and hospitals will be bundledMedicare will reimburse the hospital, which will then pay the doc-tor. Bundled payments present a nancial incentive or physicians to

become more involved in the hospitals plan o care or the patient.

For example, i the inpatient payment or a normal LOS is $4,000,

Medicare reimburses the hospital or that amount, regardless o

how long the patient actually is hospitalized. Under a bundled pay-

ment system, physicians will be reimbursed the same way.

Te early indications are that bundled payments will represent

signicant savings or Medicare. It makes sense or healthcare orga-

nizations to prepare by developing a strategy to partner with physi-cians i a bundled payment system is eventually implemented.

Whats nExt?

I youre struggling with case management issues afecting your

organizations ability to operate protably, implementing these

eight strategies will help you solve immediate challenges while

preparing or changes on the horizon. No matter where your

organizations case management capability stands today, help is

available to ensure youre positioned to handle the complex chal-

lenges that lie ahead.

case management

Deignate a eaoned cae manager who will work with the phyician advier toevaluate clinical criteria for each cae and determine an accurate tatu.