GE Healthcare Camden Group Insights Blog

Care Coordination Best Practices: The Right Care At The Right Time

Posted by Matthew Smith on Jan 16, 2018 2:17:28 PM

Care coordination becomes critically important as the acuity of patients increases, and hospitals face financial challenges as a result of readmission penalties, declining reimbursement and higher costs. Care coordination ensures hospitals provide care in the right setting at the right time, and that they achieve clinical outcomes, patient/family engagement in planning, and safe and effective care transitions. For most healthcare organizations, case managers are seen as the guardians of the care progression and discharge plans – and these three essential best practices will help both case managers as well as hospital leaders to deliver the right care at the right time.

Best Practice #1: Hold Daily Interdisciplinary Care Coordination Rounds at the Bedside for All Patients, Including Those in Critical Care Areas

The value of daily transition of care rounds has been repeatedly discussed in current literature. Moving these rounds to the bedside offers the opportunity to establish clear communication with patients and family members. Rounds should typically include the patient’s physician, nurse, case manager and any other disciplines whose interventions contribute to the progression of the patient’s care. Bedside discussions should focus on what is keeping the patient in the Hospital, what has happened in the past 12-24 hours that impacts the transition plan, and what needs to be done in the next 24 hours to remove any barriers. Moving these rounds from hallway to bedside can be difficult for teams who often express concern that involving patients could prolong discussion and make the rounds too lengthy. To address this, caregivers should be coached on ways to keep the rounds on topic, with attention to how the leader can acknowledge the patient’s or family’s concerns while deferring the detailed discussions to another time. Statements like “It sounds as if you have a lot of questions. I will make sure Jane comes back this afternoon so that we have time to go over everything” keep rounds on topic and reassure the patient that their voice is important.

When setting up daily transition rounds, don’t forget to include critical care units. Rounds in these departments often take on a more medical focus, but should be adjusted to include discussion about the patient’s progress and plan of care. Keep in mind that the ICU is a costly setting and that patients are at risk for adverse events and outcomes, making the need for focused care coordination imperative. Because of the complexity of the care provided, patients and families are often confused. Daily care progression rounds provide an excellent forum for summarizing and clarifying the plan, as well as ensuring that best practices are in place for patient safety, sedation and weaning, nutritional support, and early mobilization. For those patients experiencing prolonged stays, rounds should be used to set up complex care meetings with family members, so that they understand the possible outcomes of the patient’s course and can begin to work with case managers or social workers evaluate options. Critical care rounds, when implemented in this way, serve to improve team communication and position everyone to effectively address patient/family questions and concerns.

Best Practice #2: Include Licensed Social Workers and Registered Nurses in Your Case Management Model, and Ensure Consistent Coverage Through the Week and Extending Through the Weekend

Consistent staffing of case managers and social workers is an imperative for hospitals today. While organizations have traditionally considered case management as a weekday operation, where planned and unplanned time off could be easily accommodated by adding to existing case loads, this is no longer true. The need for experienced case management to assess patients and families, coordinate complex services to expedite safe care transitions, address the risk of readmission, and provide post-discharge follow-up requires the specialized expertise of both nurses and social workers. Coverage needs to be maintained for each unit without compromising another by attempting to absorb additional work, and extend through the weekend and Holidays to support the implementation of more complex transition plans.

Best Practice #3: Create a Strong Case Management Presence in the Emergency Department and Other Points of Patient Access to the Organization

Effective care coordination practices begin with the assessment of appropriate care settings and necessity for hospitalization. Incorporating case management nurses and social workers at all access points is the most effective way to collaborate with physicians and other providers to determine the plan of care that best meets the needs of the patient and hospital. Case management oversight should be incorporated into any patient placement process so that bed requests from post-operative and post-procedure recovery areas, the emergency department, and all other direct admission and transfer sources are reviewed. This serves as a mechanism for the assessment of medical necessity and the opportunity to identify appropriate community services to support patients safely and avoid a hospital stay. With the proposed change in requirements by the Centers for Medicare and Medicaid Services calling for discharge plans to be in place for all patients (inpatient, observation, post-procedure), the inclusion of a case management professional at the point of entry will facilitate this initial assessment, offer an opportunity for patient/family discussion, and position the hospital and care team to be more successful in creating and sharing the transition plan.

In conclusion, the changing healthcare landscape has created challenges for hospitals as well as patients and their families. As a result of new and evolving regulations by government and private payers, increased incentives to avoid hospitalization, and penalties for failing to achieve quality and safety metrics, there is clear need for dedicated professionals to coordinate and oversee patient placement and daily care processes. The burden on physicians and clinical staff at the bedside is significant as a result of higher patient acuity, further emphasizing the need for strong care coordination professionals and processes to engage the multidisciplinary team and to ensure that the care provided is safe and effective and meets the needs of the patient, family and payer.

Topics: Care Management, Healthcare Transformation

Top 10 Reasons to Integrate Your Inpatient Case Management with Your Population Health Initiatives

Posted by Matthew Smith on May 30, 2017 10:42:24 AM

By Mark Krivopal, MD, MBA, Vice President, & Tara Tesch, MHSA, Senior Manager, GE Healthcare Camden Group

Most hospitals understand the importance of inpatient case management. Yet, when asked how care managers are coordinating care for the inpatient population, most responses are focused on discharge planning tactics or utilization management strategies. The patient’s care is not truly being managed – just their length of stay (“LOS”), inpatient progress, and planning for discharge to avoid a readmission.

As the focus on value-based care is increasing, and more care is shifting into the ambulatory space while the U.S. population continues to age, a higher proportion of vulnerable ambulatory patients find themselves in need of holistic supportive care. Health systems are realizing the importance of ambulatory care management as a crucial foundation to managing populations across the care continuum by delivering high quality and patient-centric care while keeping in check avoidable costs. High performing organizations have implemented integrated care management programs focused on managing patients across care settings that include deciphering patients’ various medications, coordinating the many care directives from multiple providers, ensuring safe transitions of care from a post-acute care setting to the home, and helping patients with transportation difficulties or other social barriers to seeking care at the right time and at the right place.

The challenge though, is that many organizations are still thinking about delivering care within silos rather than integrating and aligning the initiatives within a patient-centric care delivery model. Outlined below are 10 reasons you should consider integrating your care management across the care continuum to support your population health initiatives.

1. Integrated care management addresses inefficiencies in managing the high risk populations and addresses LOS challenges and shifts in utilization to support the most effective care resource model.

The shift to value-based care delivery and the strengthened incentives for advancing value-based reimbursement will lead health systems and providers to renew their focus on adopting care models to support management of high-risk, high-cost patients, complex, and chronic care patients, in addition to disease-specific management programs. This will require new approaches to expanding patient access to lower cost sites of care and providing patients a more effective and simpler approach to navigating their care. The integrated care management model supports organizations and providers in developing innovative models (see graphic below) focused on reducing inefficiencies, managing medical spend, and improving patient access. Integration of targeted, evidence-based programs such as post-discharge transitions, complex care management, disease-specific, and episodic care pathways, as well as proactively connecting patients with behavioral health needs to appropriate care management and community services are just some of the strategies that have proven success.

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2. Duplication of care management services causes competing priorities and operational inefficiencies and redundant costs.

An integrated care management model provides a seamless patient experience across the continuum of care when there exists one aligned team to care for the patient. For organizations to achieve an integrated care management model requires not only effective communication channels and standardized care processes, but the analytics and information technology systems to support these care processes. Duplication typically occurs because barriers in technology and lack of standardization of workflow processes limit the ability of care managers to share information as the patient moves across different sites of care. Due to the limitation in electronically aggregating the necessary clinical information, care managers are not able to coordinate their efforts and spend significant time manually gathering information from providers. As a result, time is spent on manual documentation and patient management that could be automated, and more staff is typically added to ensure such information is captured, verified, and reported. The development and implementation of a shared care plan (and tools that will house the care plan) that follows the patient and is accessible by the care team, along with electronically aggregating important clinical information, are key requirements to reduce staff duplication, inefficiencies, and redundant costs.

3. One quarter of patients consume three quarters of resources, many of whom are unmanaged and lack community-based resources.

Integrated care management and coordination is a person-centered, collaborative, and multi-disciplinary process that uses population based risk-stratification and evidence-based interventions to promote optimal outcomes in a value-driven environment. By incorporating tools that allow organizations to understand the health risk level of the populations served, organizations can build more prescribed programs to track and manage high risk (and typically high cost patients), and to help prevent potentially avoidable higher-acuity, higher cost care. As organizations become more proficient in understanding the risk factors of their populations, integrated care management programs will increasingly rely on partnerships and linkages with community-based services and organizations and community health workers to help coordinate care and meet patient needs — driving the most optimal results.

4. Integrated care management addresses suboptimal transitions across the care the continuum.

The most vulnerable time for the patient is when he/she leaves the acute care setting or transitions from a skilled nursing facility back into the community. Today more patients are transitioned out of acute and rehabilitation care settings earlier than even just a few years ago. This is because more services and treatments are deemed safe to be administered in an outpatient setting. Yet, many patients are limited in their ability to thrive when one considers social determinants of health such as ability to afford medications, transportation to providers, or simply required competency level to manage their health. These factors, although likely present before the admission, are not properly addressed as part of the traditional coordinated discharge treatment plan. As a result, providers only come across these social determinants when medical errors occur, important medications are erroneously discontinued, tests are not followed up, or patients end up back in the emergency department after being discharged. Implementing patient-centric integrated care management across the continuum of care that incorporates providers expanding their discharge care plan to include social determinant evaluations helps avoid “fumbled handoffs.”

5. Integrated care management helps providers meet increased expectations around quality, cost, productivity, and patient satisfaction, critical to population health management.

The pressures on and expectations of providers (particularly primary care physicians) are immense. Physicians themselves cannot (nor should they) assume that they can address quality of care, cost, and patient satisfaction on their own. An integrated care management approach provides support to primary care practices by managing these increased expectations and helps the entire risk-bearing organization achieve success. The key is to redesign the care model to incorporate a physician-led and team-driven best practice approach. This should include integrated care plans, coordinated protocols, and outcome tracking. Providers benefit from pre-visit planning to identify complex, chronic, and high risk patients, making practice operations run more efficiently. This, in turn, leads to a more focused care plan, better managed patient flow within the practice, enhanced patient and provider satisfaction, and more coordinated overall care. By incorporating a care model that includes a significant preparatory assessment, chart reviews, and checklists to ensure preventative screening is performed and documented, providers are well-positioned to enhance the quality of care delivered and see real results within their quality performance outcomes. Those organizations that embrace an integrated care management approach find themselves better positioned to meet ever increasing demands on their expertise, time, and resources, and are better able to maximize opportunities within a value-driven healthcare world.

6. Overlap and lack of clarity in roles and responsibilities create staff dissatisfaction that can be ameliorated with integrated care management.

Over the last several years, many healthcare systems have invested substantial resources and efforts into deploying and retraining inpatient case managers to address preventable hospital LOS. As these organizations take on financial risk by participating in value-based contracting, they embed care managers in the primary care physicians’ offices to assist with managing complex patients, help with their social and behavioral needs, and improve communication around transitions of care. However, some providers are not as satisfied with this approach as one might expect. There is significant role confusion and frustration among various healthcare professionals, resulting in multiple calls to patients, for example, from home health, the care manager assigned to them by their payer, a hospital social worker, and an ambulatory care manager. Physicians are then also confused as they receive mixed messages from various care managers, which is exacerbated by lack of clarity around who they should contact in order to address some of the issues. Is it the responsibility of the hospital discharge planner to communicate important information to the ambulatory care manager, or is the ambulatory care manager responsible for contacting the hospital to get this information? Who is truly empowered and accountable for care managing the patient along the entire continuum? This can all be resolved by a single, clearly identified integrated care manager who has the responsibility to work on the patient’s behalf and serve as the single source of truth for the patient and all treating providers. Clarity around care managers’ role designation and empowerment will increase overall provider satisfaction and significantly enhance quality of care delivered to patients.

7. Integrated care management helps improve patient engagement and activation in their care.

Organizations are frequently struggling with getting patients to engage in their health in a proactive way. For many patients, active engagement in creating (and understanding) their care plan is a key to improving their health outcomes and conditions. Education and engagement with the caregivers as well as the patient is an important element in ensuring proper activation of the care plan. The integrated care manager’s care plan should include education and clear instructions to not only the patient but to care giver to ensure a common thread is formed along the complex continuum of care that bridges factors affecting patient motivation, care compliance, and the ability to activate a safe, cost-efficient, and truly patient-centric model of care.

8. Fragmented and uncoordinated care creates a poor patient experience and confusion.

When patients are battling a healthcare issue, the last thing they or their families/caregivers are thinking about is how to navigate the healthcare system. Yet, healthcare providers often overlook the basic coordination needs of patients beyond the actual treatment provided. Integrated care management is designed to ensure a positive experience for the patient and improve satisfaction in how care is provided by understanding the patient’s journey across the care continuum. Thoughtful, coordinated, and patient-centric design ensures patients remain the focus in defining processes for warm handoffs between providers and care settings, eliminating the need for the patients to repeat information or fill out duplicate forms. It provides added clarity in roles of contact with the patient, ensuring the patient/caregiver has one person to contact with questions or for support, and influences how patient materials are created and deployed (e.g., use of pictures and graphics in teaching self-care concepts, use of lay terminology rather than clinical jargon, use of teach-back and follow-up demonstrations, etc.) to reduce confusion and provide a trusted resource for patients and caregivers to access.

9. Implementing optimal integrated care management across the continuum requires support from an analytics strategy, which aligns with population health initiatives.

As organizations continue to expand their systems of clinically integrated care, building an analytics strategy that connects data from disparate IT systems will create opportunity to allow providers to act more quickly on the information. The ability to effectively aggregate data and translate that data into actionable information available at the right time, and at the point of care, should be an ever-striving goal of organizations and the foundation for effective care management. Successful integrated care management uses real time data that is turned into actionable information allowing care managers to quickly identify high risk patients and apply interventions. Gathering the right data and analyzing it correctly requires a combination of skills involving clinical knowledge, medical informatics, and technology capabilities. The analytic strategy begins with creating a culture of transparency requiring diligence in making information accessible, accurate, and easily transferrable to providers within their clinical workflow.

10. Health systems are missing opportunities to partner with payers in redesigning care delivery.

The adoption of an integrated approach to care management that is aligned with health system contracting and population health initiatives provides new revenue opportunities, when implemented successfully. By demonstrating the organization’s ability to deliver high quality, affordable care to various populations, health systems can leverage their value-based performance outcomes to engage in innovative contractual arrangements with employers and payers that align incentives across the system. Since investing in new care models and integrated care management program can be costly, it is most effective when both the providers and payers share in the investment costs and are appropriately aligned on the potential outcomes and medical cost savings. Some of this share investment occurs through innovative provider-payer partnership arrangements where the payer pays providers care coordination fees or reimbursement that is directly tied to care management services across the continuum. This will require a shared philosophy of managing care between the payer and provider as well as integrated approaches around data sharing, alignment in clinical protocols, and resource collaboration. In addition, the coordination of the care management network staff and providers aimed at promoting, maintaining, and/or restoring health will ensure a patient-centric model of care that truly spans the care continuum.

By creating a focused approach around integrated care management operations and breaking down communication barriers, organizations and providers can fundamentally transform how to deliver patient-centric care management in an integrated fashion to achieve the most optimal results possible. Well designed and properly executed integrated care management is of foundational importance for any organization aiming to achieve success within their value-based contracts. Successful implementation of an integrated care management model will empower patients and their care givers to navigate through our complex healthcare systems that lead to better quality outcomes, reduced avoidable medical costs, and improved patient and provider experience.

krivopal_M-963748-edited.jpgDr. Krivopal is a vice president with GEHC Camden Group and an accomplished senior physician-executive with 19 years of healthcare experience across the continuum of care. Dr. Krivopal is responsible for developing and leading innovative, value-based programs addressing client needs in healthcare organizations, hospitals, and physician practices focusing on transformational system integration strategies, service line optimization, throughput and clinical leadership development. He may be reached at


Tesch_T_headshot.pngMs. Tesch is a senior manager with GE Healthcare Camden Group with more than 18 years of experience as a healthcare leader and strategist. Ms. Tesch specializes in value-based care delivery strategic planning, CIN development and implementation for commercial, Medicare, and Medicaid populations, health information technology data governance and analytics strategy, as well as care management strategy, design, and implementation. She may be reached at

Topics: Population Health, Care Management, Tara Tesch, Mark Krivopal

Command Centers: Shining the Light Between the Seams

Posted by Matthew Smith on Mar 16, 2017 1:09:49 PM

Don't miss Command Centers: Shining the Light Between the Seams--co-presented by GE Healthcare Camden Group and The Johns Hopkins Hospital at Becker's Hospital Review 8th Annual MeetingApril 17-20, 2017 in Chicago.

Session Overview:

Physicians want the best outcomes for their patients, but have minimal control at the juncture where treatment delays and many problems develop--at the seams between caregivers, facilities and hospital units in a patient’s journey. That’s about to change. The emergence of command centers in hospital settings delivers real-time and predictive decision-support tools, enabling optimal decisions at the moment they are required. These technological resources permit multiple systems in an enterprise to work in harmony with each other by applying data science to redesign system dynamics across a delivery network.

The Johns Hopkins Hospital, for example, employs GE’s Command Center to reduce patient wait time in the emergency department, accept more highly complex patients, and reduce waits following surgery. The facility has experienced a 70 percent reduction in OR holds and a 24 percent increase in pre-9:00 a.m. discharge orders.

Command Centers shine a light into the seams in care, maximizing efficiency, enhancing utilization, reducing risk and improving outcomes. While there’s a lot of talk about delivering seamless care, these resources offer the missing link providers need to explore this territory and retrieve vital information at the moment it is most essential.

Presented by:

Bree Theobald, Vice President, GE Healthcare Camden Group

James Scheulen, PA, MBA, Chief Administrative Officer, Emergency Medicine and Capacity Management, The Johns Hopkins Hospital


Wednesday, April 19

3:05-3:45 PM


Hyatt Regency Chicago
151 E. Wacker Drive
Chicago, Illinois 60601

Register for Becker's Hospital Review 8th Annual Meeting:

Command Center, Capacity Command Center

Topics: Care Management, Command Center, Bree Theobald, Capacity Command Center, Capacity Management

Is Your Care Management Program Delivering Exceptional Results?

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

“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. 

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

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.


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.


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

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