Hospital group saves money with data on nurse case management
Goal is benchmarking throughout continuum of care
When most health care organizations think about acute care, they think in episodic terms. But one small group of hospitals anticipates that by extending data collection outward, it can improve patient care and save money at the same time.
"If you create a cardiac service line, you have to think about what brought [patients] into the hospital and where they will go afterward," says Lisa Zerull, RN, MSN, program director for case management at Valley Health System in Winchester, VA. The two-hospital system is one of three groups looking at nurse case management of congestive heart failure (CHF) to demonstrate how effective it can be in benefitting patients and the bottom line.
"This becomes increasingly important, because with Medicare, we don’t get reimbursed for readmissions," she continues. "We want to look at how community-based care can reduce that revolving door."
Zerull is part of a group called the Global Nursing Exchange, which meets yearly in Mexico. Two members of the group had community case management programs — something Zerull says only about a dozen health systems in the country embrace — and discussed benchmarking together so they could measure the impact.
"At first, we thought we would look at the entire patient population, but in the last four months decided it was best to limit ourselves to CHF," she explains. The group has 99 patient years of data for patients admitted under DRG 127 and is looking at everything from utilization and demographics to financial data. (For a complete list of the data being collated, see box, p. 99.)
"Intuitively, we already knew we were making a difference to the people we contact," says Zerull. For instance, one patient, a 73-year-old woman living alone with CHF and chronic obstructive pulmonary disease, had six readmissions in the last six months. She takes 12 medications and is depressed. However, with the weekly contact of a nurse case manager, she has been able to improve her compliance to take her medication. "She looks forward to the social aspect of that weekly visit," says Zerull. "The motivation is coming from the relationship, not the desire to be healthier."
Another woman had to be told by her case manager that it was OK to phone her physician if she was noticing certain symptoms. "If you teach [patients] signs of pre-crisis, they know what to do," she notes. "This woman didn’t know she could call her doc. She was just told by acute care nurses to take her meds, walk, and weigh herself. The difference in community case management is the relationship. We interact with the patient to move him or her toward better self-care and management."
But those gut instincts on the impact of community-based nurse case management don’t equate to hard data or proof that the program works, says Zerull. Looking closely at numbers and being able to find others who had similar programs became important. Zerull also says benchmarking can make the program more consistent. "We can develop an automatic way to make referrals, for instance, that doesn’t depend on whether the acute care nurses remember us." That might be a certain number of readmissions in a specified period of time, or some other factor, she adds.
Alice Weydt, RN, MS, director of patient care services at Emanuel St. Joseph’s Mayo Health System in Mankato, MN, joined Zerull in her project. She says her system was also seeing readmissions among CHF patients. "There were people falling through the cracks," Weydt explains. "They didn’t have services on discharge because they didn’t meet home health care criteria."
"A lot of us had been searching for years to find a way to compare our experiences — what we have in common and what we do not," says Cathy Michaels, PhD, RN, a postdoctoral fellow at the University of Arizona in Tucson. Formerly with Carondolet Health System’s community nurse case management program, she is the third partner in the nurse case management benchmarking program.
"We believed that we had 100% in common, but we wanted a way to show it," she adds.
Sharing information with team and beyond
Michaels says the community-based nurse case management approach offers a way to improve "team medicine." She explains that having valuable data requires you to share them with the people invested in caring for a specific population. "We have very few true team approaches. We have service lines, but not that real team approach to create a program to manage the care of a particular clinical population. You have primary, specialty, and acute care, and home care and parish nursing all in one continuum. But none of us really owns data that are valuable only to a single part of that team. Your information systems and financial people, as well as your clinical people, all have a stake in the data and the outcomes and in all parts of it."
Zerull, Michaels, and Weydt say they want to develop their benchmark for community-based nurse case management and then invite others to join. "We want to let others see our approach and go from there," explains Michaels. The group might seek a grant to ensure there are adequate resources to mine the data it is collecting. "It can be difficult to get access to data in a timely fashion and then find the staff time to analyze them," Michaels says.
Get ready to crunch numbers
Once the data are collected, the group will present and publish its findings. "We hope it will be a sample project," says Zerull. "In the 10 years I have been doing this, everyone has always wanted to look at acute care case management, but there is a change now. People are thinking about the continuum. And in a community like ours, we are the only act in town, from pre-birth to death. Whatever the level of service you need, we have to provide it."
There is still more to do. For instance, the group still wants to find a way to extract data about primary and specialty care time. "We talked about how we might get the number of visits and estimate the expense by using a standard expense for all sites," says Zerull.
The group also needs to find a physiological measure to use with CHF — something that is sensitive to the waxing and waning of the disease, but also a routine measure, such as blood sugar for diabetes, she adds.
There are other bumps, too, says Michaels. "In the business world, the service is interpreted in different ways. People think if you have a nurse doing utilization review, that’s a case manager. That’s not what we mean. If you don’t have a relationship-based practice, you don’t have what you need. One thing we hope to determine is just how much time in relationship-building you need to see that benefit."
As much as she approves of the idea of community nurse case management, Zerull says there are some things that health systems and organizations should be aware of if they intend to adopt the practice. "Technology is an issue. I had to manually enter data from the hospital into my laptop computer for four years. Without the ability to extract utilization data from the hospital mainframe, you are looking for a hard time."
Cheerleading for success
She adds that only in hospitals where there is an administrator cheerleading the project will such efforts succeed. "Without a senior level executive on your side, the cause will die," says Zerull. "You have to find the vice president who understands what you want to accomplish and have him or her there with the big guys who make the decisions."
"This is a philosophy of care," says Weydt. "One of our jobs and a big challenge in nursing is to articulate what we do and the outcomes in ways that financial people can understand. For a service not to generate revenue but to focus on cost avoidance can be a hard sell."
Michaels envisions a slow ripple effect. "There are a lot of benchmarking organizations out there, but I don’t know that they understand what is involved across the continuum of care. Maybe this will become a think tank that will ripple out slowly and grow to the point that it becomes a national benchmarking organization. But the hard part is working out what data are needed and manipulating them into useable information and from there into knowledge."
[For more information, contact:
• Lisa Zerull, RN, MSN, Program Director for Case Management, Valley Health System, Winchester, VA. Telephone: (540) 665-5344.
• Cathy Michaels, RN, PhD, Postdoctoral Fellow, University of Arizona, Tucson. Telephone: (520) 971-0680.
• Alice Weydt, RN, MS, Director of Patient Care Services, Emanuel St. Joseph’s Mayo Health System, Mankato, MN. Telephone: (507) 389 4630.]
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