Case managers develop indicators of success’
They measure success of cost; other dimensions
A Louisiana hospital has developed a new decentralized, systems approach to case management that includes relying on "indicators of success" to determine how well it is working. The system is apparently working well, because average length of stay (LOS) at the hospital has decreased from 6.1 days in 1994 to 5.4 in 1996.
Under the new structure unveiled in May 1996, formerly centralized utilization review nurses, social workers, and clinical case managers work together in a case management team model using an RN case manager and social worker, says Carole Campbell, RN, MSN, operations leader of systems improvement resources at Schumpert Health System in Shreveport, LA.
"When we did that, we wanted to put in some indicators for success and see whether we were making a difference with this new model," she explains.
A multidisciplinary design team came up with the indicators, explains Jack Olden, RN, MA, vice president for professional services at the hospital. The team consisted of Campbell, RNs who had been clinical case managers, social workers, and other clinicians.
"We looked at [factors] affecting case management, such as rejected payer claims and missed precertification," he explains. "We also looked at length of stay and cost of charges. We looked at physician, staff, and payer satisfaction with [the new model], because they are working with [case managers] every day."
The three major areas of the indicators are cost dimension, outcome dimension, and satisfaction dimension.
"In 1995 and 1996, those were our strategic objectives for the health system," says Campbell. "We used those three dimensions and then came up with specific indicators under those."
Many of the indicators have been accessible. Those that are available through the finance and business department are straightforward, because length-of-stay data and denials of admission are convenient, says Campbell. So are data obtained via computer.
"We also work closely with our management information systems to track as many of these indicators as we can," says Olden. "We try to do as much of it through our system as possible, working with abstractors from medical records to collect as much data as we can. So we don’t have to worry about our case managers having to collect data."
But some indicators have been more difficult to quantify, Campbell admits. For example, in the psychosocial area, identifying and increasing patient and family education/counseling aren’t always measurable.
"It’s not captured by any of our automated systems," she explains. "It’s a manual data collection system that our case managers and social workers have to do. At some point, you have to [determine] whether you want them to do the work or quantify the work. We still want to be able to justify their success, but we don’t want them to spend their whole day collecting data."
As a result, Olden says a team has been developed to look specifically at patient education to help improve documentation.
Some improvements have actually come about as a result of devising the indicators. Under the outcome dimension portion for clinical indicators, the design team looked at improving processes identified through a multidisciplinary action plan (MAP). For total hip and knee replacements, the team found that physical therapists (PTs) only worked on weekdays. That meant that patients who were unable to receive PT during the weekends stayed longer in the hospital and didn’t improve as quickly.
"Through development and utilization of our MAP, we identified this variance because it was impacting the length of stay and quality of patient care," Olden notes. "So one of the things we did was have the hospital support changing physical therapy [availability] to seven days a week. That’s the kind of thing you identify that affects that particular DRG, but when you improve it, it impacts care for the rest of patients in the hospital as well."
Another area that has been identified as needing improvement is subacute care for patients leaving the facility’s skilled nursing facility who may require more intensive care to get back home, says Linda Pullig RN, intake coordinator for post-acute, subacute, rehabilitation, and medical services at the hospital.
"Once patients have gone through the long-term care level, if they’re not ready for home health care yet, is there a way we could move some of these patients back into subacute?" she asks. "We want to keep that continuum where it needs to be. If we put them in long-term care, we don’t want that to be the end-all for that patient. We want to look at that individual patient and see what [his or her] needs are."
Campbell tracks the indicators on a monthly basis on a control chart; copies go to case managers and hospital vice presidents.
"We’re able to look at pre-case management and post-case management and the differences they’ve made," she explains. "We really try to visually show our indicators."
For example, for DRG 89 (community acquired pneumonia), the average LOS pre-case management in May 1994 was 7.8 days compared to 5.2 days post-case management in March 1996. (See related cost chart, above.) Overall average LOS also is down at the hospital from 6.1 days in August 1994 to 5.4 days in July 1996.
Campbell attributes much of that reduction to working more closely with home health. For example, patients who are in the hospital solely to receive an IV medication can be discharged and receive it at home.
"We feel we’ve made some really great strides, particularly in the cost and clinical dimension," says Campbell. "But patient satisfaction is also improved when you can get them back into their own homes, as long as they can get the care they need."
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