To succeed, measure CM outcomes that fit organizational goals
Strategic objectives are key to the process
The bottom line is painfully simple: If you can’t prove you provide a value-added service essential to your organization, you won’t be around much longer. You cannot stay competitive, improve your practice, or even keep your job without demonstrating your value with data.
"There have been significant changes in incentives and payment structures for health care professionals. Everything case managers do comes under scrutiny. Consumers, employers, and other key players are asking what difference you make in the delivery and quality of care. You must prove you provide a value-added service or risk being downsized," Gerri S. Lamb, RN, PhD, of Tucson, AZ, co-author of Case Management: A Guide to Strategic Evaluation, published by Mosby in St. Louis, told case managers at the recent Case Management Society of America conference in Minneapolis.
There are some essential steps case managers should take to get the biggest bang for their outcomes evaluation efforts, said Lamb’s co-author, Nancy Donaldson, RN, DNSc, director of the Center for Research and Innovation in Patient Care at the University of California San Francisco/Stanford Health Care. "Before you set out to prove your value, you must look for evidence that your outcomes are strategically aligned with your organization’s strategic objectives."
Here are 10 tips Lamb and Donaldson shared with conference attendees for case management outcomes measurement success:
1. Identify your customers. "It’s critical to think very broadly about the customers of your case management services. You also have to understand what each of your customers expects of you and what evidence your customers will accept that you are meeting those expectations," Donaldson said.
Potential customers for your services include patients, families of patients, payers, hospitals, physicians, and employers.
To make it more complicated, there is no guarantee that all the stakeholders have the same expectations and goals. For example, Donaldson noted that in her health system, the hospital is capitated for emergency department (ED) visits. "The hospital’s priority is to encourage patients to use our clinics rather than our ED. However, the ED physicians are paid per patient seen. That makes for a rather perverse incentive system! But the point is that the incentives that drive the key players in your setting are going to influence the way they view your case management outcomes."
Donaldson and Lamb suggested that case managers create three columns on a piece of paper. In the first column, list the key customers for your case management services. In the second column, next to each customer’s name, list what that customer expects of you. In the third column, list how you might measure that expectation.
If your financial people want you to help reduce costs, make sure you know how they measure cost reductions. Are they measuring cost per case? Are they measuring length of stay? Think about this very systematically, Donaldson and Lamb advised, because it is the heart of your evaluation effort.
If a strategic goal of your organization is to reduce the number of ED admissions for children with asthma, make that your goal, too, urged Lamb. "Then think about how you are going to assist children to control their asthma and prevent them from needed ED services."
2. Find strong clinical indicators. Donaldson and Lamb suggested case managers choose clinical indicators for outcomes studies that meet these five criteria:
— Standardized. "It’s always best to use indicators that have been reported in the literature. These indicators usually have a measurement formula that you can replicate," Donaldson said. Also, determine what the common measures are in your setting, she suggested. If every other case management staff in your field measures patient satisfaction using a certain tool, you must use that same tool.
Common measures used in case management outcomes studies include return-to-work, bed days per 1,000, cost per case, patient satisfaction, quality of life, functional status, and length of stay.
After you’ve selected your measures, make sure you know how your organization collects and reports them, Lamb advised. "If you’re measuring readmission rates for congestive heart failure [CHF] patients, does your reporting mechanism distinguish between readmission for CHF and admission of a CHF patient for an unrelated problem? The way your organization collects readmission data will be very important in proving the value of your case management intervention with the CHF population. If the data isn’t being captured in a way that’s useful for your study, keep bugging the people in data systems until you get what you need."
— Strategic. Make sure the indicators you select help demonstrate the impact your interventions have on your organization’s strategic goals.
— Scientifically valid. "If an indicator has been used in studies and reported in the literature, it’s usually a more useful measure," noted Donaldson. "The biggest reason for using validated indicators is that they’ve been proven to measure what you want them to measure. Validated measures give your outcomes more power."
The Internet is an excellent resource for finding scientifically valid clinical indicators, Lamb said. "The Agency for Health Care Policy and Research in Silver Spring, MD, has roughly 200 practice-based guidelines on its Web site at ahcpr.gov. Each guideline has clin ical indicators that could be used for outcomes measurement."
— Simple. "It’s always important to select indicators that are easy to use. You may even have to compromise the data you really want for the data that is readily available," said Donaldson.
The No. 1 obstacle to quality improvement efforts is a lack of time and resources, Lamb added. "The simpler you keep your evaluation efforts, the more likely you are to be able to sustain them. I constantly hear from case managers about how hard it is to keep outcome evaluation projects up and running. Be as creative as you can in using the data that is available to you. If you have to develop new data systems for measuring your case management outcomes, the harder it will be to keep your evaluation efforts going."
Setting up a system that takes all of your time and energy to maintain is the kiss of death for an evaluation effort, Lamb said. "Your data collection and analysis systems should be self-maintaining."
— Sensitive. Don’t measure outcomes that are not influenced by case management, cautioned Donaldson. "Look for outcomes that are uniquely sensitive to your case management interventions."
3. Select your target population. "Look at your total patient population. Ask yourself who the high-volume, high-risk users of services are in your population," said Donaldson. "Your outcomes measurement efforts will be more focused and more powerful if you select a population that can be positively impacted by case management."
4. Establish intervention integrity. "The integ rity of your case management interventions is directly related to your outcomes measurement power. If you’re inconsistent in delivering your intervention, strengthen your intervention before you set out to measure it or you won’t like your outcomes," said Donaldson.
"Sometimes, we have a disconnect between what we say we are going to do and what we actually do," she noted. When that happens, we have no real idea what to expect in terms of our outcomes. To be valuable, you must match your interventions to your desired outcomes and track them periodically. Never assume you’ve got any problem licked. If you’re stuck back in the quality assurance era, you’ve missed an era. Health care and business have moved onto perpetual performance improvement, and that’s where your priorities must be, too."
Consider the long term
Remember, to prove their worth, case managers must demonstrate that their interventions continue to improve outcomes over time, noted Lamb. "You must be able to show change over time. One measure before and one measure after doesn’t convince anyone."
Donaldson summed up intervention integrity with one word: consistency. "If your intervention is education for new diabetics, are you convinced that all of your case managers deliver the same information in the same manner? If not, it’s going to be very difficult to measure the effectiveness of that intervention. Also, are other health care prof essionals delivering the same information to your patients? What if the nurse in the hospital told your patient one thing and you told your patient another? You may have to meet with other professionals who interact with your patient to make sure the message your patient receives is consistent."
She suggested asking these questions:
• Is my intervention evidence-based?
• Am I relying on a validated tool for this patient population?
• Do I deliver my intervention in a consistent manner?
• Has my intervention been evaluated in the literature?
• Are there other strong reasons for me to expect my intervention to be effective?
5. Negotiate your piece of the pie. It’s very difficult to look at a patient outcome and de termine how much of that outcome is directly related to a case management intervention, noted Donaldson.
"You may have to sit down and cut deals with other departments. For example, for new diabetics, maybe case managers are primarily responsible for addressing education needs, but the system’s home health nurses also provide education on diabetes management for new diabetics. You may be able to negotiate with the home health agency for the right to claim 80% of the savings from the diabetic education intervention and let the home health agency claim the remaining 20%," she said.
6. Make friends. Donaldson and Lamb suggested case managers make friends with key personnel in their organizations who can help them collect and analyze their data.
"We hope to make it perfectly clear that there are a number of people you should definitely take to lunch," Donaldson quipped. "You must cultivate these people to make your job easier and also to make sure your efforts are on target with your organization’s goals. Remember, once you implement an outcomes measurement effort, you hope to continue it over time. You want to add to the population measured and track the evolution of your improvement effort. You’ll need help from others in your organization to do that."
Donaldson and Lamb suggested befriending the following people:
• quality improvement staff;
• outcomes management staff;
• information systems staff;
• financial staff.
"The finance people are very important to your efforts," said Donaldson. "You must learn how to speak their language and produce data that is relevant to them."
7. Find partners. There is no need to reinvent the wheel, noted Lamb and Donaldson. "Two heads are always better than one. You need to find and work with partners and mentors. If you have a population in common with another case manager in your area, or a practice setting in common with another case manager in your region, take advantage of that," Donaldson urged.
"Use each other’s data for comparison. Your data is meaningless unless you benchmark yourself against someone else. You may have reduced your cost per case by $5,000 and still not be competitive if your cost per case is the highest in your area," she said.
8. Collect baseline data. You can’t prove the effectiveness of your case management interventions without collecting baseline data for your target patient population, noted Lamb. "It’s simply hard to say you’ve made an improvement without baseline data for comparison."
(Collect ing baseline data is an important step in designing an outcomes study. Models for outcomes studies are discussed on p. 169.)
9. Give interventions time to work. Never measure your outcomes until your interventions have had time to have an effect, cautioned Donaldson. "Make sure everybody is in place delivering the goods before you look at whether the goods have been delivered."
Two to three months is the minimum time period for many case management interventions to begin having a measurable effect, added Lamb. "Even then, it’s a good idea to start with a small pilot study."
10. Report your findings. "Don’t minimize the skill it takes to tell people about your findings. Too many case managers spend all their energy collecting and analyzing their outcomes and then share their results in two minutes or less," said Lamb.
"It takes time to present data so that it appears credible to others. Know the members of your audience and have a good understanding of what will be credible to them," she said.
For example, Lamb noted that physicians take a different standard of evidence than "financial folks." If a physician asks you whether your study was a double-blind, placebo-controlled study, you had better be prepared to explain why it wasn’t, she said.
"Remember when you’re trying to get the point across that case management works, the motto is: In God we trust. For all others, bring data!’" Donaldson said.
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