Healthcare organizations operate under an ever-changing and complicated set of rules, regulations, laws, and standards. Paul Starr (Harvard University, 1982) is credited with labeling the hospital as “the most complex organizational structure created by man.” It can be a daunting task for healthcare leaders to set priorities and to plan for the future sustainability of their organization. Which of the myriad of regulations will the Congress or the Centers for Medicare and Medicaid Services change in the coming years? What are the two presidential candidates expected to do if elected? Will the Affordable Care Act (ACA) be radically changed, or will it remain largely intact? How can we best position ourselves to negotiate favorable contracts with our payers? What is our population health strategy? And the list of questions continue…
A high-performing care management program is one of the few programs that can help a healthcare organization succeed, regardless of what the answers to these questions turn out to be. Your organization’s strategy on volume versus value and a robust and effective care management program will help you drive towards desired results. Without comprehensive care management throughout the continuum of care, your organization will likely struggle to achieve its strategic goals. Here are 10 questions to ask to help you evaluate your care management program.
1. Does your care management strategy extend beyond the four walls of the hospital?
“Strategy without tactics is the slowest route to victory; tactics without strategy is the noise before defeat.” – Sun Tsu
In the past, case management (as it was often called) was a service to be consulted by the inpatient care team, often long after hospital admission, if the team felt the patient might require complex discharge planning, such as placement in a skilled nursing facility, or need durable medical equipment (DME) at home. That is the model of the past.
In today’s demanding healthcare market, your organization must expand the role and responsibility of your care management department to include a strong focus on, and alignment with, your population health strategy. This includes comprehensive discharge planning (both from the inpatient arena as well as the Emergency Department ["ED"), including the scheduling and monitoring of aftercare appointments, ongoing monitoring of patients with a high risk of readmission (such as congestive heart failure), and appropriate short and long-term placement in skilled nursing facilities. These activities are also dependent-upon a strong healthcare information exchange infrastructure that is not limited when communicating clinical information beyond your four walls.
A successful population health strategy must have clearly defined care model principles, aimed at providing clinical effective care in the safest and most cost effective way, thus improving the care of the patient while simultaneously improving the bottom line of your organization. A comprehensive care management program is the vital foundation to this critical strategy. It requires an integrated care management process and communication to assure that patients have one care plan that follows them, rather than reinventing the plan between care venues. Be sure that your ambulatory care managers, who may be embedded in primary care practices or specialty service line venues, and the inpatient care management staff are organized as a seamless care management team for the health system.
2. Do you have a clearly defined care management model that is the best fit for your unique organization?
“Unless structure follows strategy, inefficiency results.” – Alfred D. Chandler
There are a variety of widely accepted care management models in use across the country. These include the traditional model, dyad model, partially integrated dyad model, integrated dyad model, triad model, hybrid model, etc. Confused yet?
While many have strong opinions about which model is “best,” they all have pros and cons, and it is important to examine each in order to determine the best fit for your particular organization. But far more important than which model your organization employs are two key questions: a) Is the model clearly understood and applied consistently and efficiently and b) Does the model have the full support of both the hospital and physician leadership? If the answer to either of those questions is anything other than an unqualified “yes,” you are unlikely to have a highly successful care management program.
3. Are you using an established tool and most current practices to perform Utilization Review ("UR")?
“If I had nine hours to chop down a tree, I’d spend the first sharpening my ax.” – Abraham Lincoln
CMS requires that all participating hospitals employ a structure and process to determine if a patient qualifies for inpatient or observation status. Hospitals use a variety of tools to accomplish this UR process. These include commercially available screening products, such as InterQual or Milliman, as well as home-grown solutions. As with the care management model, which UR tool an organization chooses is less important than utilizing that tool correctly and having a clear structure and process in place for the Care Manager (CM) and physician to communicate the output of the initial UR. Often the difference in appropriately classifying a patient as an inpatient, rather than observation, is a small amount of additional documentation by the physician.
4. Do you have a comprehensive care management dashboard used to drive results?
“Without data you’re just another person with an opinion.” – W. Edwards Deming
In the world of the electronic medical record (EMR), most organizations have access to myriad data points. They can pull reports on almost anything they wish; however, this “data” is often aggregated and unverified for accuracy. Many healthcare leaders complain of “data overload,” where they struggle with what data to focus on in order to drive results.
A comprehensive care management dashboard contains the following elements:
- 10-15 evidence-based, operational data points
- All data points have been validated and benchmarked
- Aggressive but appropriate goals have been set for each metric that is under-performing
- The dashboard is “pushed” to the end-user, rather than “pulled” by them
- A clear escalation of accountability, from the individual CM all the way to the C-suite
- An operational group/committee that is tasked with monitoring the dashboard results and driving improvement
- Transparency of the data, the goals, and the accountability
5. Are you staffing appropriately to demand?
“Coming together is a beginning. Keeping together is progress. Working together is success.” – Henry Ford
Many organizations struggle with how to determine if they are staffing appropriately to meet the demands of their patients, while remaining mindful of the bottom line. Whether it is nursing ratios on the inpatient unit or the number of environmental services staff on the evening shift, it is critical to balance operational and financial goals.
Care management programs are staffed in a variety of ways, primary driven by the CM model discussed previously. Depending on the CM model, the makeup of the staff (i.e., nurse, social worker, support staff), the complexity of the patients, and other factors, there is an appropriate staffing plan for your organization. Designing these plans can be complex, because the best plans incorporate a wide variety of variables, but when an organization can harmonize the financial and operational goals simultaneously, they achieve optimal staffing in their care management program.
6. How do you measure length-of-stay ("LOS")?
“Measurement is the first step that leads to control and eventually to improvement. If you can’t measure something, you can’t understand it. If you can’t understand it, you can’t control it. If you can’t control it, you can’t improve it.” ― H. James Harrington
As with any data point, evaluating whether your organization is accurately capturing and reporting LOS can be a byzantine task. Here is the first problem – the most accurate and actionable LOS calculation is not the average LOS ("ALOS") that many organizations have been using for decades. Why? It tells you almost nothing that is actionable about your operations. If your ALOS went from 4.1 to 4.6 last fiscal quarter, what does that tell you? Other than your “average” patient spent more time in the hospital, it tells you little else. Also, what does an “average” patient look like? Were they admitted for myocardial infarction, a planned orthopedic surgery, or did they present to the emergency department in septic shock? Were they a readmission?
In order to have the maximum impact on meeting the organization’s LOS goals, the data must be examined far beyond averages. A comprehensive examination of the organization’s LOS data should involve the following elements:
- ALOS (this is still useful for internal benchmarking)
- Observed versus expected LOS
- Case mix index
- Severity adjust LOS
- LOS by:
- Service line
- Benchmarking against peers, using one or more benchmarks, including, but not limited to:
- UHC and other commercially available databases
- CMS Geometric Mean LOS
7. Are service lines/specialties incentivized and or aligned with organizational goals?
“If everyone is moving forward together, then success takes care of itself.” – Henry Ford
If your organization has adequately addressed all of the other questions herein, it’s time to take a hard look at whether there is internal alignment. How does your organization align goals and accountability with your providers, both employed and otherwise?
To maximize goals around care management efforts, not only LOS, but also prevention of readmissions and adequate clinical documentation, the organization must align those goals with the providers. Though incentivizing the providers to drive towards those same goals can be time-consuming and complicated, the benefit of doing so is incalculable.
8. Is care management supporting the ED to prevent unnecessary admissions/readmissions through shared decision-making at the time of admission?
“Teamwork is the ability to work together toward a common vision. The ability to direct individual accomplishments toward organizational objectives. It is the fuel that allows common people to attain uncommon results.” – Andrew Carnegie
The ED is, with few exceptions, the portal through which the majority of hospital admissions originate. Although the largest quantity of admissions may come through the ED, they are often admissions with far lower contribution margin than those who enter the organization through a portal such as the OR. They are also sometimes the admissions with little to no value to the patient or the organization.
In a strong care management program, the case managers in the ED should be the front-line of defense in preventing readmissions, “social” admissions, and other inappropriate types of admissions. This may be accomplished by processes such as:
- Automatic, real-time notification of the ED CM by the EMR upon the arrival in the ED of a potential readmission.
- Establishing an ED care management committee, led by an ED Case Manager, in order to identify and evaluate ED “Super Users,” and develop an individualized care plan for each of those clients in order to reduce both ED visits and admissions to the hospital.
- Developing a robust network of up-to-date contacts that the ED Case Manager can call upon to assist them in the development of an appropriate discharge plan and follow-up care following an ED visit.
As noted above, a robust care management program in the ED is invaluable to prevent readmissions and unnecessary admissions, but the program should also be the “tip of the spear” when it comes to the care management process and services for an admitted patient. Ideally, the majority, if not all, admissions from the ED should be screened by a case manager using an appropriate utilization tool, as noted earlier. This requires buy-in from the Emergency Medicine providers, who may see this additional step as something that can have a detrimental effect on ED flow, or simply something that has to do with the inpatient arena. This is a prime opportunity to align service lines with hospital goals, as discussed earlier. The ED must be part of the solution when it comes to patient classification and management across the continuum.
9. Do you have a clear escalation and resolution policy to support CM?
“None of us is as smart as all of us.” – Ken Blanchard
What happens when your talented and educated group of case managers runs into a barrier? Whether that barrier be one of your own providers who does not support the case manager’s status evaluation (e.g., inpatient versus observation, etc.), a payer that issues a concurrent denial of care, or perhaps a family member who does not agree with the decision to discharge their loved one, a high performing care management program must have a robust and effective escalation and resolution policy in place. Such an escalation pathway often looks like the following:
Each link in this pathway gives yet another opportunity to achieve a successful outcome for the organization, the patient, and the family. Not only does it continuously bring a fresh perspective and set of skills to bear, when dealing with a payer, oftentimes, repetition, escalation, and documentation can be the key to a favorable outcome.
10. Do you have a comprehensive in-house Physician Advisor (PA) program?
“A coach is someone who can give correction without causing resentment.” – John Wooden
In a highly effective care management program, the PA provides counsel to the case management department, clinical documentation improvement (CDI) team, and the hospital leadership on matters regarding physician practice patterns, resource consumption, medical necessity, and compliance with government regulation. The PA also provides coaching and formal education to the medical staff and maintains collaborative relationships with payers. The PA is a member of the organization’s leadership team charged with meeting goals of quality and cost reduction.
Many organizations have one or more PAs in place who deal with and resolve clinical cases, on a case-by-case basis, in a highly effective manner, and consider this be a successful implementation of a PA program. Without the other elements of a PA program, noted above, there is work to be done. One of the most powerful uses of a PA is leveraging them to prevent escalations in the first place. This is accomplished through a robust education program and coaching aimed at their physician peers, so that they may better understand regulations, charting requirements, etc. Ironically, a motivated PA should be working to put themselves out of a job.