Demonstrate effectiveness of your CM program
For proof to administration, go beyond cost, LOS
No matter how effectively your case management department functions, all your efforts will have gone for naught if you can’t use data to prove your worth to administrators at your facility and officials at the managed care companies with whom your hospital contracts.
The easiest and most common way to assess performance is to benchmark using comparative billing data. Such data are easily accessible, fairly cheap to acquire, and "they do tend to point you in areas where you may be a high utilizer compared to other facilities," says Judy Homa-Lowry, RN, MS, CPHQ, a consultant with Homa-Lowry Healthcare Consulting in Canton, MI.
Even so, not all billing data are created equal. For example, Medicare data are easy to get, but they’re only published annually and tend to be older than data from other payer sources. Medicare claims data from last year are only now becoming available. On the other hand, "all-payer" data may be published quarterly, but they’re more expensive and may be more difficult to analyze and interpret.
Whatever combination of data sources you draw from to benchmark your case management efforts, one key measure of the success of your program is how well your pathways perform. Although pathways are typically evaluated in terms of broad statistics, such as average length of stay and costs or charges per case, examining them in terms of other, more specific measures can give you a clearer picture of their success, Homa-Lowry says.
"It’s important to get down as best you can to specific utilization of services when evaluating pathways," she says. For example, have complications been diminished or poor outcomes improved as a result of the pathway? What about patient satisfaction? Have relationships with other clinicians along the patient’s continuum of care become more supportive? In a supportive system, Homa-Lowry notes, long-term care and home care provi ders cooperate to help decrease length of stay and reduce the rate of readmissions. "We see patients view the transition into alternate care delivery systems as a positive experience, and they’re ready for it," she says.
Questions to ask when evaluating the success of your pathways include:
• Are they targeting high-volume, high-risk areas successfully?
• Do they serve as tools for providing additional analysis?
While you might have one standard for evaluating the success of your program, hospital administrators and managed care organizations may have different expectations of you, Homa-Lowry notes. Of course, everyone’s interested in costs vs. benefits and how well you measure up in terms of the usual broad parameters, including length of stay, cost, charges, outcomes, and satisfaction. But hospital administrators also may evaluate your success at least partially in terms of how well you’ve helped the hospital increase or decrease its market share.
Compare yourself to competitors
Administrators want to see whether you’re able to identify potential business opportunities, Homa-Lowry says. "If you find that you’re doing a good job in an area where [another facility] is not, you might have an opportunity to expand services in that area," she adds.
Another, more subjective measure of your success in the eyes of administration may be whether and to what extent you’ve influenced the behavior of the physicians you work with.
Managed care organizations, on the other hand, take a more global view of how well your organization utilizes services. "They’re looking at how well people are treating various diseases or product lines and how they can influence the number of resources," Homa-Lowry says.
Bear in mind that managed care organizations compile their own comparative data as well. If they identify your hospital as an overutilizer in a given area, they may in fact target your case management department for increased scrutiny. "It may be done in a very subtle way by asking the managed care case managers to examine things more closely and look for additional data," Homa-Lowry says. "I always tell people, if your external case managers begin focusing in more on a particular disease or market, it would be good to take a look at that and evaluate your data to see what they’re trying to do."
For more information about evaluating your case management program, contact:
Judy Homa-Lowry, Homa-Lowry Healthcare Consulting, 7245 Provincial Court, Canton, MI 48187. Telephone: (734) 459-9333.
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