By Toni Cesta, PhD, RN, FAAN
Introduction
Today’s competitive healthcare environment demands constant attention to improvements in quality, safety, and the patient’s experience with care. Patients are demanding that they receive full value for their healthcare dollar. The goal of any healthcare provider, including case managers and social workers, is to have patients want to return to them when necessary for their healthcare needs. If healthcare organizations fall short on quality and safety, they will be at greater risk in the highly competitive marketplace in terms of patient care and now, in terms of reimbursement, as well. Focusing on quality and safety allows healthcare organizations to achieve many benefits, which may include:
- Efficient use of resources and services.
- Meeting the demands, interests, preferences and needs of patients.
- Enhancing patients’ and families’ experiences with care, including satisfaction and engagement.
- Provision of compassionate, ethical, and culturally competent patient/family-driven care.
- Ensuring patient safety through timely and appropriate care, reduced risk for injury, avoidance of medical errors, prevention of healthcare-acquired conditions, and safe disposition or discharge from acute care settings.
- Professional and satisfactory performance by providers, including case managers and social workers.
- Lowering cost of care and health services by eliminating unnecessary use of resources, duplication, and fragmentation of services while ensuring continuity and care progression.
- Ensuring reimbursement in an era of value-based purchasing.
What Is Quality of Care?
Probably the most difficult hurdle before us is the meaning of “quality” in today’s healthcare world. What are the properties, characteristics, and attributes of care that lead us to a judgment of good or poor quality? Is it an optimal or suboptimal care experience? Is it high cost and poor outcomes? Is it lack of access to healthcare? Quality means different things to different people: the providers, regulators, payers, advocates, and consumers of healthcare.
Historically, the healthcare providers have defined quality. However, since the mid-1980s, our patients have become more involved in defining what constitutes quality of care and are influencing the perception of providers and payers of healthcare. Recently, healthcare regulators have begun defining quality and are strongly influencing its focus and how it is assessed and measured, especially by linking reimbursement to cost of care, quality of care, and perception of health by the consumer of the care. This evolved recently, and in a prominent way, as a result of value-based purchasing and the Affordable Care Act. This recent shift necessitates healthcare organizations and providers to show increased commitment to quality and incorporate quality, safety, and the patient experience into their strategic plans, mission, and vision.
For more than a decade, the Institute of Medicine’s (IOM’s) definition of quality has been widely accepted. The quality focus is on the patient, rather than provider- or payer-centered. It promotes the application of evidence in practice and examines the consequences of care delivery using objective measures. The IOM defines quality as “the degree to which healthcare services for individuals and populations increase the likelihood that desired outcomes are consistent with professional knowledge,” available at the time care is provided to individuals and populations.
IOM describes quality using six domains. These domains have been used to articulate what quality is, and what focus one must take when assessing and improving it. They are consistent with the aims of case management and the roles of the case manager and social worker.
The following are the IOM’s six domains of healthcare quality:
- Safe: Care should be as safe for patients in healthcare organizations as in their homes.
- Effective: The science and evidence behind healthcare services, resources, and care approaches should be applied practice and serve as the standard for the delivery of care.
- Efficient: Care and service should be cost-effective, and waste should be removed from the system.
- Timely: Patients should experience no waits or delays in receiving care and services.
- Patient-centered: The system of care should revolve around the patient, respect patient preferences, and put the patient in control.
- Equitable: Unequal treatment should be a thing of the past; disparities in care should be eradicated. (For more on the six domains of healthcare quality, visit: http://bit.ly/2plr8hf.)
In fact, these six aims align with many definitions of case management. For example, the Case Management Society of America’s (CMSA’s) definition reads as follow: “Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes.” (More information on the CMSA definition and philosophy of case management can be found at: http://bit.ly/1oJMfzL.)
The six aims also align with the American Case Management Association’s (ACMA’s) definition: “Case management in a hospital/healthcare system is a collaborative practice model that includes patients, nurses, social workers, physicians, other practitioners, caregivers, and the community. The case management process encompasses communication and facilitates care along a continuum through effective resource coordination. The goals of case management include the achievement of optimal health, access to care, and appropriate utilization of resources, balanced with the patient’s right to self-determination.” (More information on the ACMA’s philosophy can be found at: http://bit.ly/2q2XcXO.)
Is there any doubt that case management plays an important role in the management of quality outcomes of care based on these definitions and our understanding of quality?
Our patients’ own definitions of quality is dependent on their needs, interests, preferences, values, and equitable access to services and resources. It also is dependent on their health literacy, or ability to understand health information in a meaningful way. Although these may vary from one patient to another, what is important to them is the opportunity to be the drivers of care delivery. Patients will tell us that they want to feel welcomed, that they are important, made comfortable by healthcare providers, and are understood. In addition, patients appreciate providers with a friendly, compassionate, and supportive attitude and with technical skills and knowledge. They also appreciate cleanliness and comfort in the physical environment of care.
Quality of care may include, but is not limited to, available healthcare services, standards of providers, comprehensive assessment and documentation, shared decision-making, collaborative and informed relationships with patient and family, minimal to no injuries or complications for hospitalized patients, evaluation of new technology and resources, and effective management of healthcare resources. Along with patient satisfaction and safety, the patient’s view of what is important in his or her care may be seen as one aspect of quality when defining indicators and measures of quality. The overall quality of healthcare will be judged on the entire package, including health outcomes, accessibility, timeliness, efficiency of services, interdisciplinary communication, and the direct and indirect costs of illness and care.
Quality Happens at the Local Level
Quality of care can happen each time we speak to a patient, educate him or her, or advocate on his or her behalf. Though the patients’ and providers’ definitions of quality are not always the same, it is important for providers to define quality and desired outcomes of care based on the needs, values, and interests of their patients. This alignment is necessary so that the individuals accessing healthcare will have a positive experience concerning the services provided to them and that they are of optimal quality, safety, and free of errors. It also is important for healthcare providers (both individual professionals and organizations) to incorporate the regulators’ perspectives on quality, safety, and cost in their focus to ensure adherence to standards, meeting expectations, and reducing or avoiding financial risks.
As members of the healthcare team, we must be cognizant of these each and every time we interact with the patient, the family, and the family caregiver. Case managers and social workers play an important role in providing the link between the cost of care and the quality of care. We do this in ways that are specific and unique to the specialty of case management.
Quality and the Case Manager
As a case manager or social worker, you play an integral role in ensuring your patients receive the highest level of care possible. You do this when you assess them, conduct a clinical review, prepare a discharge plan, or expedite a delay in delivery of care. While you may not have the primary responsibility of monitoring quality, you and every member of the healthcare team have a responsibility to ensure that care is timely, appropriate, and meets a minimal standard of quality. In addition, as case managers, we also must ensure that the care to be provided at the next level following the inpatient stay is timely, appropriate, and meets a minimal standard of quality.
Outcomes of Care
Outcomes of care can be thought of as the measures used to examine whether the goals or objectives of the care rendered and the services provided have been met. They are an important tool in the case manager’s tool box. Outcomes can be categorized in various subsets or classifications. They are the end results and consequences of care delivery, affected by the characteristics of the patient and family, the providers of care, the patient’s insurance coverage, and the healthcare system in general.
As you intervene on behalf of your patient and family member, you must be sure that each intervention also includes an expected outcome that is prospectively identified. Typically, case managers use the clinical endpoints as indicators for when a patient has completed a particular stage in the care process and can be moved to the next level.
The outcomes can be linked to the clinical guidelines you use for your clinical reviews, such as the InterQual guidelines. For example, a drain might be removed postoperatively after the drainage has decreased to a predetermined and acceptable amount/volume per hour. As case managers, we play a role in ensuring that the drain is removed on time and as appropriate. This is our role in the management of patient flow.
We also can use the achievement, or lack of achievement, of the expected outcomes for clinical insurance reviews to ensure that reimbursement occurs and, when necessary, those additional hospital days are approved by a third-party payer. In these ways, outcomes can be a powerful and dynamic tool that provides the case manager with objective indicators to use for a variety of purposes.
Outcomes also can be used effectively when linked with discharge and transitional planning. By moving the patient toward a predetermined set of outcomes, the time for discharge or transition to the next level of care is driven by the patient’s achievement of those expected outcomes and is not based on arbitrary time frames. In this way, the case manager can defend the time at which a patient should be discharged if the patient, family, and/or physician are resistant. The case manager can defend the need to extend the hospital stay in the event that a premature discharge or transition is identified based on a review of the patient’s progress.
Linking Structure and Process to Outcomes
Case management has been described as a structure and process model, linking both to the outcomes of care. When applied effectively, it improves patient care quality and safety and reduces unnecessary cost while enhancing the patient’s experience. Because case management links the three elements of structure, process, and outcome, case managers can serve an important function in assisting their organizations in the measurement of quality of care. As case managers review the patient’s achievement of the expected outcomes of care, they also can review the processes used to achieve these outcomes. The processes, as identified on the diagnosis-specific case management plan, become the standard of care for patients with that diagnosis. The patient’s ability to reach the expected outcomes is dependent on the selection of the most appropriate processes for achieving these outcomes. It also is dependent on the organization’s processes supporting the care interventions needed. For example, perhaps the case management plan calls for an MRI on day 1 of the acute hospital stay. What are the consequences if day 1 happens to fall on a Sunday, when MRIs are not routinely performed? The patient’s stay most likely will be prolonged, quality care will not be provided as per the case management plan, the patient’s satisfaction with care will suffer, and reimbursement may be at risk. The case manager, by intervening to correct these delays and then collecting them for later analysis, can provide the organization with meaningful information that may assist in making organizational improvements, while also correcting the delay at the patient level. Both approaches improve outcomes of care and, therefore, quality of care.
Another example is the switch of a patient from an IV antibiotic to its oral form as soon as it is appropriate. The case management plan may call for the switch to take place after several prerequisite clinical outcomes have been met. In the case of community-acquired pneumonia, the switch from an IV antibiotic may depend on the patient’s achievement of a reduced white blood cell count, a reduction in fever, and the ability to take oral medications. What might happen if the patient achieves these outcomes, but the attending physician does not write an order for the switch to take place? This may result in compromising the quality of care, prolonging the hospital length of stay unnecessarily, and increasing the cost of care or sustaining a denial in reimbursement by a commercial insurer.
Summary
Case management’s efforts for improvement in outcomes and quality of care must be accomplished on a case-by-case basis. Case management plays a crucial role in evaluating and monitoring a patient’s plan of care and outcomes such as discharge goals and avoidable readmissions. Case managers are the professionals most aware of the patient’s functional, physical, cognitive, emotional, and socioeconomic abilities and know best how these abilities may affect and determine a patient’s level of functioning after discharge/transition from an acute care setting or an episode of illness. Offering the best possible discharge or transitional plan is vitally important because of the potential for reducing readmissions and providing alternative care methods for less cost — and the ultimate outcome of heightened patient, family, physician, and payer satisfaction. Being able to manage your patients’ expectations of quality care must be the driving force. This is the central reason why a registered nurse or social worker is best positioned to be a case manager. Quality and efficient care should be a way of life for any case manager on a day-to-day basis, and it is one of the standards necessary today for healthcare to prosper and survive.
Today’s competitive healthcare environment demands constant attention to improvements in quality, safety, and the patient’s experience with care.
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