You're only as good as yesterday's discharges Strategies to demonstrate case management's value
By Toni Cesta, PhD, RN, FAAN
Senior Vice President
Lutheran Medical Center
Brooklyn, NY
[Editor's note: This month we include the first part of a two-part series on demonstrating the value of case management to your organization. We cover metrics to measure and goals for your department. In next month's issue, we'll continue with examples of benchmarking and case management report cards.]
Since the mid-1980s when case management moved into the hospital setting, departments have been struggling to find the best ways to demonstrate their department's effectiveness. Over the years, these metrics have become increasingly sophisticated and have moved beyond the realm of simply measuring length of stay or the number of discharges.
Every hospital budgets its expected discharges for the day, the week, the month, and the year. Invariably, members of your hospital's executive staff monitor these numbers routinely and are satisfied when the targets are met and are dissatisfied when they are not. So, often we are challenged to show our value in more than just discharges or length of stay. The measures are among the most challenging things we do and require a structure, goals, and access to accurate and timely information.
Hospitals are complex organizations, and outcomes take the efforts of many individuals working as a team. Case management outcomes often are the result of the efforts of the case managers along with multiple other departments and disciplines. This makes the measurement of case management outcomes complex and challenging.
Productivity measures often are the only outcome indicators used. These are typically measures of workload and include indicators such as number of clinical reviews completed each day, number of discharges to nursing homes or home care, or how many patients were seen by the case manager. The measures define the workload of the case manager or social worker but not the effect of that work on the organization.
Categorizing outcomes
To select the outcomes you would like to measure, a good first step is to consider them in more than one category. Examples of these would include financial, clinical/quality, service, regulatory compliance, and productivity.
The next question to ask is, "What data do I currently collect"? The department must identify what data are collected and/or reported, as well as who sees the data. Consider any data that are being reported by other departments, as the reporting of these data might be redundant and dilute the effect of the message that case management is trying to send out with its data.
Case management outcome levels
When considering which outcomes you will use, also keep in mind the fact that there are different level of outcomes. This means that some of the outcomes by be affected in one of three ways:
- Organizational outcomes: affected by multiple departments / disciplines
- Departmental outcomes: affected by the case management department
- Staff outcomes: affected by individual staff members.
If the outcomes you select are organizational outcomes, consider providing a disclaimer on your report indicating that the outcomes are the results of multiple departments or disciplines. Providing a disclaimer like this will help to demonstrate the team philosophy of the case management department. For example, for an organizational outcome such as length of stay, the case management department may want to state that "case management is one of many departments and disciplines that have an affect on length of stay."
Financial outcomes
Financial outcomes are relevant as they relate to many of the functions performed through the case management department. Most of these outcomes are affected by case mangers as well as other departments and disciplines and are reflective of the over-all efficiency of the hospital. Members of the physicians' staffs have a significant impact on financial outcomes. Collaborating with the physicians' staffs can have a positive impact on resource utilization, length of stay, and over-all cost per case. (See more on these outcomes, below.)
Consider these other metrics:
Observation hours.
The average number of hours a patient spends in observation is an important metric. Patients who remain in observation for greater than 24 hours should be considered for conversion to inpatient status. The case management staff should work closely with attending physician to monitor and manage these timeframes.
The case management department also should track and trend the total number of avoidable days and compare this number to the total number of excess days. Excess days are the total number of hospital days beyond the geometric mean expected length of stay for all discharges. Not all excess days are avoidable, and the case management department should report the variance between the avoidable and excess. By doing this, the hospital can better understand which excess days are truly avoidable and focus on these for performance improvement.
Clinical /quality outcome metrics.
The case management department's effect on the organization also includes its effect on quality of care and clinical outcomes. Quality indicators are more difficult to quantify because they typically cannot be associated with a financial metric. However, because the very basis of case management is founded on the notion that it bridges the clinical and financial worlds, it is imperative that the quality outcomes be given just as much attention as the financial outcomes.
Service outcomes.
Case managers might consider placing patient satisfaction under the category of service or quality. In either case, it is an important metric. Also included under service should be physician and staff satisfaction. Issues to consider when measuring patient, staff or physician satisfaction include:
the measurement tool and specific questions selected;
measurement frequency;
which staff you want to measure for satisfaction;
which case management roles and functions affect satisfaction.
Regulatory compliance.
Monitoring the departmental compliance with regulatory indicators is important as a measure of the compliance of the department but should be kept separately as an indicator. Examples might include:
providing patients with "choice" lists for home care and nursing homes;
appropriately documenting discharge planning assessments;
using Condition Code 44;
appropriately documenting patient discharge disposition.
Productivity.
Productivity measures are indicators of the volume of work performed by the department. Although they might give an indication of the amount and complexity of the work, these numbers alone don't demonstrate the organizational outcomes, but rather the volume of the work itself. If monitored, they should be used for the internal evaluation of the department and of the case management staff and should be used within the department only. The department leaders might find, however, that they need to evaluate the work performance of individuals in the department to demonstrate the need for more staff members. In these circumstances, productivity measures are appropriate.
Case management leaders might consider using some of the productivity measures to evaluate staff member's performance with their annual performance review. Examples of staff productivity measures include:
caseloads;
number of patients discharges with services by type of service;
number of case management assessments completed;
number of case management assessments completed within 24 hours of admission;
number of insurance reviews completed;
number of interventions on avoidable day issues;
avoidable days capture rate.
Selecting goals for your department By Toni Cesta, PhD, RN, FAAN Every case management department should have three important documents in its policy manual. These are a vision statement, a mission statement, and departmental goals. These documents should be reviewed annually and updated as needed. When writing the department's goals, consider the following:
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