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GE Healthcare Camden Group Insights Blog

Is Your Care Management Program Delivering Exceptional Results?

Posted by Matthew Smith on Oct 11, 2016 4:19:34 PM

By Court Curneen, RN, MS, CEN, EMTP, Senior Manager, GE Healthcare Camden Group

stethoscope-resized-600-1.jpg“If I had an hour to solve a problem I’d spend 55 minutes thinking about the problem and 5 minutes thinking about solutions.” – Albert Einstein

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
    • Provider
    • Group
    • DRG
    • Unit
  • 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.


Curneed.jpgMr. Curneen is a senior manager in the Care Design and Delivery practice at GE Healthcare Camden Group with over 20 years ofexperience in the pre-hospital and acute care hospital settings. His clinical background comes from roles as a paramedic and a registered nurse, with experience in the emergency department (“ED”), criticalcare, cardiovascular, aeromedical, and emergency medical services environments. Mr. Curneen’s areas of focus include hospital operations and strategy, process improvement, case management, patient experience, and ED operations. He may be reached at court.curneen@ge.com.

 

Topics: Care Management, Care Design, Hospital Operations, Care Design and Delivery, Court Curneen

Coordinating Care Across the Continuum

Posted by Matthew Smith on Aug 19, 2014 12:19:00 PM

By William K. Faber, MD, MHCM
Chief Medical Officer
Health Directions

Continuum of CareQuality and value in health care are driven not just by excellence in discreet locations of care, but in the coordination of care between sites and practitioners. Quality health care is the result of a team effort rather than the talents of individuals. Many of the failures of health care occur during the transitions between the doctor’s office and the hospital, or between the hospital and home, or between doctors’ offices. Value in health care is driven in large part by two major factors: selecting the appropriate site of care and the quality of the communication between the sites of care.

The Continuum

The “continuum of care” is a current buzz phrase in health care. It acknowledges that people need different kinds of health care services throughout their lives and that not all of this care needs to be delivered at the hospital, which is the most expensive place to receive care. We can think of health care as a spectrum of services that start with primary prevention (e.g. immunizations) and progresses to secondary prevention (e.g. medicines to lower cholesterol), diagnostic services, outpatient treatment, inpatient (hospital) treatment, rehabilitation services, skilled nursing services, home health, palliative care and hospice. To control the cost of care, we should ask “what is the lowest cost setting in which we can deliver the needed care with excellence?”

Examples of care delivered in unnecessarily expensive sites include: giving IV antibiotics in the hospital when they could be given at home or in a skilled nursing facility, certain surgeries being done in a hospital when they can now be done well in ambulatory surgery centers, utilization of urgent care centers when the same care could be delivered in a regular doctor’s office, and palliative care at the end of life in an intensive care unit instead of a hospice. Over the past 20 years, many services have migrated out of the hospital to the benefit of the consumer. Hospitals have to pass their high overhead on to patients in the form of charges. Hospitals should be reserved for care that can be competently delivered nowhere else.

It is incumbent on systems that would provide high quality, low cost care to actively select and direct patients to the best place of care for their need. Guiding patients to the best site of care is rightfully the role of primary care providers and care managers.

Transitions

Even if we are successful in differentiating care into cost effective locations, and are additionally successful in guiding patients to the most cost effect sites, we are left with the challenge of seamlessly handing off patients (and all pertinent information about them) between those facilities and practitioners. Imagine transporting sand from one bucket to another using your hands alone. Some of the sand falls between your fingers in transition. Think of the sand as bits of medical information as a patient is transported from one site of care to another. 

Examples of waste and risk that result in from poor transitions include: repeating an expensive test, such as an MRI, because the second facility does not know that the first facility already did one; patients getting home without knowing the change in the dose of the medications they see on their kitchen counter; and the results of a test done in the hospital which come back after the patient has left which never get reported to the patient. Countless tests get reordered for want of solid transition management. Thousands of patients get unnecessarily readmitted to the hospital each year because they are confused as to what they should do after leaving the hospital.

The Solution: Care Coordination

Healthcare is complex and disjointed. Traditional payment systems reward the efforts of individuals. Emerging forms of payment challenge us to invest in new, patient centered services that provide the “glue” between individual services. Care coordination can be enhanced by the use of care managers, information system integration, handoff protocols, and discharge instructions.

Care Management: Care management takes many forms: disease managers, hospital discharge planners, social workers, office based care managers, insurance company care managers, individual doctors and nurses, and family members. Ironically, care management often stops at the boundaries of the entity that is paying for the care.

The gold standard in patient-centered medical care would be for one, primary care manager to be linked to a patient and his or her family to assist in navigation regardless of the hospital system, form of insurance or phase of care. This one person would be well known and trusted by the patient, take global responsibility for the well-being of the patient and would be on “speed dial” for the patient and his or her closest family members.

The greater the breadth of the care manager’s involvement, the more effective they will be in reducing waste and risk. Care managers should be concerned with the very practical issues of transportation and financial resources for the patient.

Referrals to specialists or outpatient tests are useless if the patient does not have a ride. Prescriptions are useless if the patient cannot afford them or take them.

Information Systems: Even though most systems and providers have now converted to electronic health records, the dream of digitized information has not yet been realized, because systems do not automatically “talk to” one another. Some providers use their EHR as a dictation service and do not create structured notes with searchable fields of information. Provider concerns for privacy puts a block on the free exchange of information between parties who would benefit from the free flow of information. Hospitals and physician offices are often on different EHR platforms. Some of this can be overcome by campaigns to get patients to sign releases to share information. Some can be overcome through the use of Health Information Exchanges (HIEs), and some of this can be overcome through “push” messaging or protocols that prompt providers to send notes to important recipients on the team in a timely manner.

For instance, a system could adopt and support policies that patients being discharged from the hospital should have a follow up appointment in their PCP’s office within three days of discharge before they even leave the hospital with a complete discharge summary in the hands of that PCP before the patient arrives. A complete discharge summary would list all new medicines, changes in medication dosages, all new diagnoses, all significant procedures and test results and all pending test results and recommended post-hospitalization testing and specialty appointments.

Similarly, Primary Care Providers should communicate with the Emergency Department and or hospitalist team whenever they are aware of one of their patients who is heading to the hospital, to fill that doctor in on what medications the patient is taking, what tests have already been done, and the psychosocial context of the trip to the hospital. Is this the seventh time the patient has gone to the ER for chest pain in the past three months, despite repeated negative workups for cardiac disease? The best information systems allow inpatient providers to and outpatient providers to directly access the same unified electronic record.

About the Author

William K. Faber, MD Health DirectionsDr. William K. Faber, Chief Medical Officer for Health Directions, is a physician executive with progressive senior leadership experience. He most recently served as Senior Vice President of the Rochester General Health System in New York, where he guided the development of the system’s Clinical Integration program and assisted more than 150 providers at 44 sites through the conversion process from paper records to an Electronic Health Records system (Epic). Dr. Faber formerly participated in the governance of the Advocate Physician Partners (APP) Clinical Integration program and directed APP’s Quality Improvement Collaborative.

 

Clinical Integration, Health Directions, Clinically Integrated Network

Topics: Continuum of Care, Care Management, William K. Faber MD; Primary Care Provider

10 Attainable Benefits of Clinical Integration

Posted by Matthew Smith on May 12, 2014 1:58:00 PM

Clinical Integration, Health DirectionsIn today's healthcare landscape, there are a wide-range of approaches and strategies employed to achieve successful clinical integration (“CI”). Regardless of the strategy, when designed and implemented correctly, CI offers tremendous potentials for efficiencies and improvements in healthcare quality and patient satisfaction.

Here are 10 identified benefits of CI to consider when exploring your CI options and feasability:

1. Increased Collaboration: The use of care teams to implement a CI program addresses gaps in the care continuum while reducing ineffective or unneeded process steps. This approach allows hospitals and healthcare providers to learn to operate as a team to better align, or realign, their efforts to improve quality, patient safety, and patient and family satisfaction.

2. Improved Efficiency: CI eliminates healthcare waste and redundancy, making it possible for hospital systems to provide patients focused seamless systems of care across and between healthcare providers.

3. Integrated Systems: CI programs provide hospital systems with many more monitoring and enforcement tools than through a typical medical staff organization, including the payment of financial incentives for physicians who actively participate in the program and penalties for those who do not.

4. Payer Partnerships: As CI improves the quality of patient care and clinical processes and reduces costs, hospitals are able to achieve market differentiation. This type of differentiation is attractive to health plans and can serve as the catalyst for payer partnerships.

5. Improved Care Management: Organizations that are successfully clinically integrated benefit from improved care management. Patients who see multiple doctors are well aware of the fragmented and redundant services and care they receive. Case management serves as the foundation to accomplish coordination of care across traditional health settings. Its goal is to achieve the best clinical and cost outcomes for both patient and provider and is most successful when case managers are able to work within and outside organized health systems.

6. Integrated Continuum of Care: At the center of CI is teamwork among healthcare providers working to ensure patients get the right care at the right time in the right setting. CI care management teams collaborate with adult day care, independent living, assisted living, and skilled nursing facility partners. Together, with infrastructure focused on supporting caregivers and patients to efficiently assess, document, communicate, and meet patient needs enables hospital systems and healthcare networks to achieve this core objective.

7. Clinical Data Systems: An integrated technology (“IT”) platform that supports continuity of care and enables access to medical history and critical patient data for all stakeholders is imperative in CI, easing communications across the care continuum and providing information that measures service, performance, quality, and outcomes on an individual provider and network-wide basis.

8. Patient-centered Communication: In many networks, communication skills training is provided to physicians and healthcare providers with the goal of establishing clear channels of communication as a vital part of the CI program. The Joint Commission has cited communication breakdown as the single greatest contributing factor to sentinel events and delays in care in U.S. hospitals. The CI emphasis on timely and clear communication is key to influencing patient behavior, resulting in cost/quality benefits.

9. Improved Pharmaceutical Management: Most medication errors are not caused by individual carelessness, but rather by faulty processes that lead people to make mistakes or fail to prevent the mistakes. CI improves pharmaceutical management allowing hospitals to identify gaps in the medication management process and allow them to take actions to help make patients safer.

10. Improved Health of the Community: CI emphasizes wellness initiatives such as outreach programs and classes to empower the patient with tools, knowledge, and practical solutions to participate actively in their care, ultimately leading to a healthier population. Extensive research in the past three decades indicates that receiving wellness and prevention advice and care from trusted local hospitals and physicians resonates with individuals.

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Topics: Clinical Integration, Daniel J. Marino, Continuum of Care, Care Management, Clinical Data Systems

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