Critical Path Network
Balanced scorecard helps CMs focus on improvement
Charts show trends in LOS, charges, readmissions
A balanced scorecard showing case mix, length of stay, charges per case, and other data on a monthly and quarterly basis helps the case managers at INTEGRIS Rural Health focus on areas where their hospital needs to improve.
"The balanced scorecard shows the big picture of how hospitals in the system are performing and how individual physicians and case managers are performing. It shows trends in our length of stay and charges per case, but there’s a lot more information than that. It ties in with our quality initiatives, the core measures, and what we need to be doing to get ready for the next Joint Commission on Accreditation of Healthcare Organizations [JCAHO] survey," says Denise Caram, MS, CPUM, CPUR, director of support services for INTEGRIS Rural Health, an 11-hospital system based in Oklahoma City.
The balanced scorecard shows data for all patients, with data for Medicare/Medicaid patients broken out separately. In rural Oklahoma, a high percentage of patients are Medicare or Medicaid beneficiaries, Caram says.
The information on the balanced scorecard is compiled from medical records data that each hospital sends to the corporate office. Caram’s assistant downloads the information, puts it into the balanced scorecard format, and sends it to Caram, who passes the information on to all of the hospitals.
"Each hospital is totally different, but seeing the data from the other hospitals gives them an idea of how they are performing in comparison to the rest of the system," she says.
The balanced scorecard helps Caram keep a close eye on the performance of the case management departments at the 11 rural hospitals scattered across Oklahoma, many of which have only one case manager.
The hospital system started out creating a balanced scorecard only for Medicare patients, then expanded it to track all patients. Medicaid patients were added in April 2006.
At INTEGRIS, the case managers report to the chief financial officer.
"I felt like the CFO would be more likely to take the case management activities seriously because it affects the bottom line. In addition, the CFOs and administrators have a better understanding of the case management process, not only from the clinical side, but they also get to know the practice patterns of our physicians as well," she says.
The scorecard for each hospital shows trends over the past year broken out by quarters, including the overall med/surg length of stay, overall med/surg charges per case, and case-mix-adjusted med/surg charges per case. The data are broken out by all patients, Medicare patients, and Medicaid patients.
It also includes the indexed length of stay, which shows whether the length of stay for patients in the hospital’s diagnoses mix is within the guidelines for commercially insured patients or the geometric mean length of stay for Medicare patients.
"The indexed length of stay looks at length of stay as well as case mix. It shows us whether patients are going home too soon or if we are keeping them beyond the geometric length of stay for that DRG. If the indexed length of stay is too low, the hospital may have an increase in readmissions. When a hospital has a lower length of stay, it’s not necessarily an indication of quality, especially if the case mix is up," she points out.
The balanced scorecard breaks out data for the top-volume med/surg DRGs, tracking trends in the geometric mean length of stay and charges per case over a one-year period.
It shows Medicare coding efficiency, physician-specific indexed length of stay, and case manager-specific length of stay for med/surg DRGs, and it shows readmission rates within 30 days for top-volume med/surg DRGs.
Caram looks at each hospital’s balanced scorecard monthly. After reviewing the data, she e-mails the local case manager to point out areas where improvement is needed and to suggest what might be done to improve.
For instance, if the length of stay is particularly high for a given DRG, she suggests that the case manager look at the hospital’s charts and determine whether there is a specific physician who is driving the high length of stay. The hospital system uses a physician-aligned model of case management and has developed standard order sets for the top DRGs.
"Each hospital can look at the balanced scorecard and see if there is a physician who isn’t following the hospital’s order sets or who frequently has patients whose length of stay exceed the norm," she says.
Recently, one hospital’s data showed that the patients of 11 doctors had lengths of stay that exceeded the norm. Caram e-mailed the CFO and the case manager to make sure they were doing something to correct the problem.
"It’s a collaborative effort. I’m not berating them. I just point out areas where they need to focus their improvement initiatives," she says.
For instance, if the data show that the charges per case are too high for a particular DRG, the case manager looks further to find out which physicians are responsible for the overutilization.
"We have begun to look at the quality side. If we are having a lot of readmissions, we look at why. We drill down to the individual physician and take our data to the medical staff," she says.
Caram and the case managers present the scorecard to the local hospital boards on a quarterly basis, share it with the medical staff, and use it in utilization management activities.
"When we have our quarterly administrative team meeting at each hospital, the administrator and the CFO come prepared to tell us why the length of stay is up or why they are having an increase in readmissions. One facility that wasn’t doing so well has started turning around since they have seen the data. The balanced scorecard shows them why they need to change," she says.
When the case management activities were first standardized across the hospital system, Caram instituted quarterly educational sessions, bringing all the case managers together to share patient strategies, discuss changes in Medicare and other reimbursement, and learn from each.
"These case managers had a clinical background but not a financial background. They didn’t realize the impact their department could have on the hospital. Initially, I had to do a lot of teaching on the financial side," she says.
Now the meetings are held twice a year, and Caram is planning a retreat for the case managers that will include an expert speaker to discuss where case management needs to go in the future.
Caram talks to the case managers at each hospital twice a week, on Monday and Thursday.
"On Monday, we discuss the census and where we’re going. On Thursday, we discuss how we can get patients who are nearly ready for discharge out before the weekend," she says.
If a patient has been in the hospital for six days on Thursday and the case manager doesn’t get him or her discharged before the weekend, the patient will have been in the hospital for 10 days by the time Monday rolls around, Caram points out.
"We’re not trying to push them out if they’re sick, but it’s good to have a discussion," she says.
For instance, nursing home admissions on the weekend tend to be a problem, causing delays in discharging the patient from the hospital.
To alleviate the problem, one case manager has built a relationship with a local nursing home that now will take patients on the weekend.
All the rural hospitals received a grant from the INASMUCH Foundation, a state-level nonprofit organization based in Oklahoma City, to provide additional money for patients who may need assistance with medication, transportation, education, equipment, and other needs.
"This in turn has generated enthusiasm for the hospitals to do some fundraising," she says.
The case managers screen the patients before helping them with medication. If the patient comes to them several times, the case manager offers to pay part of the cost of the medication if the patient will pay the rest.
"Making sure that patients get their medications is a good way to keep them from being hospitalized again," she says.
A balanced scorecard showing case mix, length of stay, charges per case, and other data on a monthly and quarterly basis helps the case managers at INTEGRIS Rural Health focus on areas where their hospital needs to improve.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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