creating data-driven strategies to improve hospital outcomes: a case manager's guide

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CreatingData‐drivenStrategiestoImproveHospitalOutcomesA Case Manager’s Guide

Data

Information

Knowledge

Annual National InstituteOctober 16, 2014


1. Learn to connect the value and impact of hospital case management efforts to key metrics; Review a sample of a scorecard

2. Understand how to establish and use a framework for evaluating and improving key hospital case management processes and outcome metrics

3. Learn how to develop governance practices needed to produce high‐quality data and achieve accountability

4. Identify data management strategies to support decision making, performance improvement and regulatory compliance

Objectives


“Acute Care Case Management is a collaborative and facilitative

process of business, interpersonal, and clinical strategies that, when

successfully applied, effects more efficient delivery of care, reduces

variations in the consumption of clinical resources, and produces

improvement in clinical and financial outcomes.”‐ The Leader’s Guide to Hospital Case Management, Stefani Daniels & Marianne Ramey, 2005

Utilization Management, Care Coordination, Transition Management‘Right Care, Right Setting, Right Time’

Clinical Revenue CycleClinical Business Management

HospitalCaseManagement(HCM)


HCMProgramCharacteristics

Leading Programs:• Data‐driven Performance

Improvement• Focus on Care

Transformation and Outcomes Management

• Well‐developed Infrastructure

• Alignment with Medical Staff Leadership/ Hospitalists

• Respect and Authority

Challenged Programs:• Access to Data• IS Data Integrity• Effective Reporting Tools• Knowledge/Skill• Day‐to‐Day Focused


Categories Examples

Regulated/ Must Do

Data to support Utilization Review & Discharge Planning CMS CoPs processes are followed ‐ IP Status Requirements, Status Changes, Beneficiary Notices Delivered, Documented ‘Patient Choice’

Compelled To Do Readmissions ‐Risk For… Reasons Why… Avoided How….

Monitoring/ Seeking Opportunities

“Avoidable Delays” Tracking –Delays attributed to: Hospital Depts, Physician, Patient/Family, and External/Community

Strategic Initiatives Length of Stay Management/Throughput;Post‐hospitalization Services Referrals – In and out of network or ACO referrals

Demonstrate HCM Value

Status OBS IP; “Avoidable Delay” Avoided; ED Patient Readmission Avoided; Concurrent Appeal Successful

HCM Productivity Utilization Reviews Conducted; SW Referrals Initiated/Completed; Post‐hospitalization Services Set‐up

HCMData


“Instead of payment that asks,

‘How MUCH Did You Do?,’

the Affordable Care Act clearly moves us toward payment that asks,

‘How WELL Did You Do?’

and more importantly,

‘How Well Did the PATIENT Do?’”

‐ Don Berwick, MD, MPP

Former Administrator, Centers for Medicare and Medicaid Services

(CMS)

President Emeritus and Senior Fellow, Institute for Healthcare

Improvement (IHI)


Revenue Increase Revenue Decrease AvoidanceCapacity Management

Length of stay/Throughput Management to improve bed capacity and patient volumes (when unit capacity is an issue); Add the value $$ of filling the bed

Readmission (Unplanned) Reduction

CM or SW in the ED intervenes, sets up services and facilitates release of a Medicare heart failure patient recently hospitalized; Readmission prevented; Readmission rate improves, $$ penalty avoided

Qualifying Bedded Outpatients (OP) as Inpatient (IP)

OP observation patient’s inpatient admission facilitated after the Case Manger applies criteria and discusses case with the patient’s physician can net $6,746 avg./case

Delay/Denial Avoidance/ Mitigation

Care is well coordinated, barriers removed, in order to minimize costly delays and payer $$ denials

Concurrent Appeal

Clinical appealmanaged prior to claim and when successful, retro denials management avoided “X”$$

Expense Decrease Compliance Risk/Penalty AvoidanceResource Utilization/Efficiency

Orders for duplicative or unrelated tests are ‘caught’ and cancelledreducing excess utilization and cost per case: Tests/Studies (“X” $$ of each)

Accurate IP/OP Status; 2 MN Rule

CMS Billing Compliance;‘Recovery Auditor’ defensible

Facilitated Transition/ Throughput

A ‘case rate’ or ‘self‐pay’ patient’s discharge is expedited once discharge readiness was determined: $450 (Average) multiplied by “X”# Excess Days

CMS Utilization Review and Discharge Planning CoP Compliance; Accrediting Standards

Survey readiness and success

CoP = CMS ‘Conditions of Participation’

HCMImprovedClinicalRevenueCycle Outcomes


HCMImprovedClinicalQualityOutcomes

Collaborative Practice/ Patient Experience Patient Outcomes

Interdisciplinary team communication Readmission reduction

Medical staff as partners Patient intermediate and transition outcomes

Patient involvement & adherence to the plan of care

Effective, safe, timely, and complete transitions (discharge)

Care Transformation Patient Safety & Quality Measures

Monitoring/ managing care Evidence‐based practice

Data‐driven performance improvement Clinical process of care (Core Measures)

Transparency Safety and mortality (HACs)

Delay avoidance/ mitigation

Hospital Case Management contributes as an integral member, and often times the driver, of the interdisciplinary team to achieve optimal clinical quality outcomes.


• Start with strategic, meaningful metrics (aligned with targets/incentives)

• Develop a subset of tactical metrics (root caused focused)• Balance (anticipate the impact of relationship between metrics):

LOS with readmission rate or satisfaction; OBS volume with IP volume; Initial denials with appeal overturn rate with clinical denials write‐offs

• When selecting metrics, back into what you want with what you can get through external benchmarking

• Definitions! Report ‘run’ dates

HCMScorecard


HCMProgramScorecardSAMPLE


HCMAnalyticsFramework

Fact‐Based Decision

Making and Alignment of Resource Use

Information Needs Assessed & Identified

1

Future State Design & Build2

Sustain & Optimize

3

Analytics and

Reporting4


1.InformationNeedsAssessment

• Identify data needs: Mandatory Strategic initiatives Compelled to do Performance improvement:

o Clinicalo Financialo Operations

Internal reporting:o Utilization Review Committeeo Quality Management Committee

o Corporate Reporting, as applicable

• Data sources: Case Management System(s) ADT/EMR Other organizational

applications


CommonCMDataManagementIssues

• Data scattered throughout the organization

• Disparate IT systems: Data redundancy Data isolation – no interfaces

• Multiple sources of data: Internal corporate databases Government reports Knowledge – personal

experiences and thoughts

• Access to data: Security Timeliness

• Data integrity• Lack of clinical analyst

support






1


Sustain & Optimize

3

Analytics and

Reporting4


• Define data sources for agreed upon metrics: Accountability parties Reporting frequency

• Mitigate inefficiencies: Interoperability Information system purchases Current system redesign Electronic communication workflows

• Enhance effectiveness: Automate tasks to increase timeliness of reviews/interventions

• Establish Clinical Analyst support

2.FutureStateDesignGoal:Gettheright informationtotheright peopleattheright timeintherightamountandintheright format


2.FutureStateBuild

Get the right information to the right people at the righttime in the right amount and in the right format.

Build:• Data dictionaries (fields defined)• Data workbook (list of terms)• Redesigned workflows• Data quality control processes:

Auditing procedures Auditing reports

• Staff educational programs and job aids

• Reports• Reporting scheduling• Dashboard(s)


ExampleDataDictionary:AvoidableDelays(AD)Data Field Name Screen/Tab

DictionaryType Definition

R= Required/ O=Optional

Start Date AD Home Page Date Enter the first AD R as applicable

End Date AD Home Page Date Enter the end AD R as applicable

# Days AD Home Page Calculated The number of days impacted is calculated for you

Location AD Home Page Location Select the location of the patient for the date(s) of the AD O

Entered By AD Home Page EmployeesThe person whose professional judgment determined the Avoidable Day/Delay R as applicable

Hospital DRG AD Home Page InterfacedOnce the patient is discharged and the record is coded, the MS‐DRG will populate via the interface

Comments AD Home Page Free Text Document AD activity not captured by the dictionary fields R as applicable

Cause Attributed Cause Cause Select the attributed cause of the AD R as applicable

Days Attributed Cause Free Text Enter the number of days associated with each cause R as applicable

Attribution Attributed Cause DepartmentsSelect the hospital department attributed with the AD, as applicable R as applicable

Physician Attributed Cause ProvidersSelect the provider/physician attributed with the AD, as applicable R as applicable






1


Sustain & Optimize

3

Analytics and

Reporting4


• Conduct data integrity audits Data processes and documentation

• Maintain data dictionary and workbook• Coordinate software upgrade activities• Manage provider correspondence and fax processes

• Assess changing information needs; recommend solutions

• Build and/or generate auditing reports

3.HCMAuditor&ClinicalDataManagement


20






1


Sustain & Optimize

3

Analytics and

Reporting4


4.KeyCapabilitiesofHCMAnalytics&Reporting

Key Performance Indicators (KPI)• Ability to produce the specific HCM measures identified through the data needs assessment

Trend Analysis• Short‐, medium‐, and long‐term trends of KPIs to help project and forecast changes in performance

Drill‐down• Ability to go to details at several levels

Ad‐hoc Analysis• Analyses made any time, upon demands, and with any desired factors and data relationships

Status Access• The latest data available for a key metric, ideally in real time

Critical Success Factors• Identify the factors most critical for the success of HCM and the organization


• Varying levels of knowledge and skills Data management Data not viewed as an asset

• Decisions are becoming more complex requiring sophisticated analysis

• Most decisions must be made under time pressure

• Information overload• Lack of IT tools to help perform all

the tasks related to information processing and management

CommonHCMAnalytics&ReportingChallenges


• Customized reports and dashboards• Increases trust

Reports: Advances Accuracy and Meaningfulness

• Eases the collection, maintenance, and analysis of information• Harnesses expertise of HCM clinicians and analytic staff

Analysis: Ensures Conclusions are Valid

• Efficiencies and success• Progress related to strategic objectives and action plans• Competitive performance• Ability to respond rapidly to changing needs and challenges

Data Review: Assesses for …

• Deployed to departments, teams, and organization

Findings: Translates Into Improvement Priorities

HighQualityDataforAccountability


DevelopandFosterKeyPartnerships

• Partner HCM with an analyst, not just access to ‘analytics,’ in order to provide your organization meaningful business intelligence and develop the HCM leader’s analytical skills Diminish challenges of data

accuracy

• Physicians as partners with HCM: Work with the medical staff and its leaders early on to earn their buy‐in and develop the best uses of data

• Revenue cycle: HCM is the bridge between finance and clinical Collaborate to get past

differences and improve communication and outcomes

o Medicare Billing Compliance “Achieving Accurate Reimbursement & Compliance”


DevelopTeam‐BasedApproach/Interventions…ToImprovePatientandOrganizationalOutcomes

Interdisciplinary Review of ‘Actionable Data’/Audit Risk Areas:• PEPPER and other

benchmarking data• Avoidable delay tracking

Report HCM Program Analytics with Action Plan Recommendations to Key Committees:• Utilization Review & Medical

Executive Committees• Revenue Cycle Management

Committee• Quality Committee and the

Quality Committee of the BoardInclude HCM in organizational quality and performance improvement activities/work teams


InfluenceBehaviorwithData

• Hold others ‘kindly’ accountable• Select meaningful metrics• Conduct cost analyses to perform

‘corrective’ tasks: Code 44s Provider liable claims (12x) and post‐

bill self denials Surgical Status (IP/OP) errors

• Provide data/analyses to those that can impact the improvements: HCM staff; patient care units; medical

staff Performance Improvement

Committees Diagnosis/DRG‐based data

Promote a culture of enhanced transparency, true quality care, service, and

transformation


EmployTacticalEfforts–Example:LOSDailyFlash

DEFINITION• (N): A count of the # of

acute inpatients exceeding the threshold, counted at the same designated time each day (MN)

• (D): A count of the total # of acute inpatients, counted at the same designated time each day (MN)

• Acute: All inpatients excluding mother‐baby, psych, IP hospice, rehab

Target >4 Days: 25% (TBD)Target >10 Days: 6% (TBD)

115

120

125

130

135

140

145

150

0%

5%

10%

15%

20%

25%

30%

35%

40%

Acute IP Cen

sus

% Acute Cases Exceeding

4 or 1

0 Days

31‐Mar 1‐Apr 2‐Apr 3‐Apr 4‐Apr 5‐Apr 6‐Apr 7‐Apr 8‐Apr 9‐Apr% >4 Days 34% 31% 29% 27% 25% 24% 23% 28% 23% 24%% >10 Days 6% 7% 9% 10% 11% 9% 6% 7% 6% 6%Census 138 139 135 130 132 129 128 132 130 134

Acute LOS Flash


Knowledge=Improvement=Success

HCM ValueRevenue Increase & Decrease Avoidance; Expense Decrease; Compliance Risk & Penalty Avoidance

Data Governance and Management

Effective Decision‐Making, Improvement

and Compliance

HCM Optimization – Organizational, Clinical, Financial


It’sNationalCaseManagementWeek!

CMSA

ACMA


Questions

Contact Information:

Lana Cabral, RN, BSN, MSM, CMAC, CRCRSenior Director, Case Management Services

Conifer Health SolutionsEmail: [email protected]

Michele Szymborski, CPHQ, CSHAManager, Case Management Services

Conifer Health SolutionsEmail: [email protected]

Appendices


HCMKPIDefinitions

33


HCMKPIDefinitions

34


• A surgeon requests OR time for a Medicare a patient’s procedure and orders Outpatient Status; Upon checking the procedure is determined to be on the Medicare Inpatient‐Only List; a corrected Status order is obtained prior to the start of the procedure; Revenue Decrease Avoided

• Case Manager intervenes when duplicative or unrelated tests are ordered, reducing excess utilization and cost per case : Tests/Studies (“X” $$ of each); Expense Decrease

• A ‘case rate’ or ‘self‐pay’ patient’s discharge is expedited once discharge readiness was determined: $450 (Average) multiplied by “X”# Days; expense decrease and if a capacity issue add the value$$ of filling the bed; Revenue Increase

• A ‘per diem’ patient’s avoidable delay in care is avoided with Case Manager intervention: “X”$$ (per payer contracted rate); revenue decrease avoided or Case rate Cases: $450 (Average) multiplied by “X”# Days; Expense Decrease

• A concurrent clinical appeal is conducted and is successful: “X”$$ (per payer contracted rate); Revenue Decrease Avoided

• The Case Manager coordinates the multiple consultants’ plans with the interdisciplinary team and the patient/family, streamlining the progression of the patient’s treatment, decreasing length of stay; either Reducing Expense or creating an open bed to be filled‐Revenue Increase

HCM‐ MakingtheBusinessCase


• A hospitalized outpatient Observation patient’s inpatient admission is facilitated after the Case Manger applies criteria and discusses case with the patient’s physician: $6,746 (Average); Revenue Increase

• Social Worker in the ED intervenes, sets up services and facilitates release of a Medicare heart failure patient recently hospitalized: Readmission prevented; Readmission rate improves, Penalty Avoided

• Case Manager’s Medicare patient does not meet InterQual and refers case to the Physician Advisor who applies the CMS definition of inpatient care and approves the inpatient admission; Revenue preserved/Compliance; Risk Avoidance

• Medicare inpatient not meeting criteria, the Case Manager follows CMS Code 44 process involving UR Committee physician; Billing Compliance; Risk Avoidance

• The review of a new patient’s record indicates an opportunity to advance the plan of care, the Case Manager intervenes and with the addition of physician orders the patient’s progression of care is advanced, length of stay is decreased ; eitherReducing Expense or creating an open bed to be filled‐Revenue Increase

HCM‐ MakingtheBusinessCase (cont’d)

creating data-driven strategies to improve hospital outcomes: a case manager's guide

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