Justifying case managers pays off for hospital
Statistics show how CM affects the bottom line
Before the Floyd Rehabilitation Center in Rome, GA, hired its first case manager four years ago, the hospital administrator told Karen Sablon, director of case management, she could create the position if she thought it was needed. Now, in these lean times when every position has to be justified, Sablon is ready to show the financial staff just what case management can do for a hospital."A lot of people in the past have said case management isn’t revenue-generating. But it allows the clinical staff to do what they are supposed to do and increase productivity," Sablon says.
When the center added a pediatric case manager, for instance, the productivity of the therapists increased 12% in the first six months, she says. "They had more time to treat patients because they didn’t have to deal with insurance people."
Case managers as marketers
At Floyd, all members of the case management department also function in a marketing role, and Sablon tracks the increase in referrals to show it’s paying off. (For details on marketing by case managers, see story, p. 26.)The rehab center is part of Floyd Medical Center, which includes a 304-bed acute care hospital with an inpatient rehab component, outpatient rehab, a community respiratory care center, a home health agency, a durable medical equipment agency, a hospital, a primary care physician group, and the new occupational health program.
To justify the day hospital case manager, Sablon is tracking the average daily census and growth for the outpatient program among patients who were in the day hospital. She projected that the case manager would help maintain an average daily census of five patients and that the outpatient population would grow, and she has compiled monthly records that back up her assertion.
"We’re still not revenue-producing, but we are showing that we have productivity and that we are affecting the bottom line," she says.
With the new occupational health center, which opened late last year, Sablon is working to show what case management can bring to the organization financially.
"As time has gone by, the hospital administration is asking for data to show how case mangers will contribute. A lot of it has to do with reimbursement. What we could get three or four years ago, we can’t get today. Now we have to justify every new position and show how it can add value to the organization," she says.
To justify the need for an occupational health case manager, Sablon plans to show the hospital administration how a case manager can help keep patients from leaving the Floyd Medical Center system.
"If a person comes to our emergency room after being injured on the job, then is sent to a specialist who refers him to another facility for lab work, we’re losing this patient," she points out.
She is compiling statistics on workers’ compensation case costs and comparing them with costs for patients who came through the hospital without case management.
"We can show that the average patient costs a certain amount, and we didn’t generate that much because the patient didn’t stay in our system. Case management can help us keep that patient," she adds.
At Floyd, two admissions coordinators for inpatient rehab, both registered nurses, screen the patients who are referred to the center and handle the insurance negotiations that have to be done on an individual basis.
Sablon is expanding the role of the admissions coordinators so when they screen a patient who is not appropriate for inpatient rehab, they can recommend a referral to another part of the health care continuum, such as the day hospital or home health program.
Two case managers in the inpatient program are social workers who handle case management along with the counseling, psychosocial issues, and discharge planning process. The case managers work closely with the families, determine what the patient will need after discharge, and follow through with the insurance companies as needed.
There are separate case managers for the pediatric outpatient program, the day hospital, the outpatient center, and the new occupational health component. When patients come in for their first appointment in pediatric or outpatient adult services, the case manager meets with them, gives them her phone number, and discusses their rights, responsibilities, and the hospital policies for cancellations.
"If patients have a question or a problem, they can talk to the case manager. When patients know only the therapist, they may have a hard time getting them on the telephone because the therapist is treating patients. Often the case manager can solve the problem on the spot," Sablon says.
The outpatient case managers handle a case-load of 25 to 30 patients in addition to taking in new referrals, scheduling first-time evaluations, and greeting new patients. On the inpatient side, the case managers handle about 15 patients at a time. In addition to traditional case management duties, they provide psychosocial and family counseling.
Sablon also plans to coordinate case management with the hospital’s home care and hospice services so patients will receive coordinated care throughout the continuum.
When the rehab center opened in 1974, the admissions information was sent to the nursing unit and the nurses had to get the data from the referring facility or physician, get approval for treatment, and act as a liaison with payers.
"It can take hours to verify a patient’s benefits and get approval. This took a lot of the nurses’ time and affected their productivity," she says.
Before the pediatric case manager was hired, it was up to the therapists to schedule pediatric patients for their first evaluations. Often there was a long lapse between referral and evaluation because the therapists were trying to schedule appointments between their other duties.
"Now that case management is doing it, the therapists have less down time and patients don’t have to wait as long to get in. Case management schedules the patients while the therapists are treating other patients," Sablon says.
When the rehab unit opened, the assessment tool for approving patients for the program consisted of just one page. Now, it’s grown to four pages because of payers’ demands for more justification, she says. "We were getting denials because the insurers said we weren’t giving them a clear enough picture. In the past four years, we’ve redone our assessment tool twice to give them the clear picture they need."
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