Pushing Case Management into the Future: Six Requirements to Drive Clinical and Financial Returns Authors: Loren Mann, Mark Werner, MD and Cynthia Bailey Hospital-based case management (CM) should be a key driver of clinical quality, financial performance and patient experience. What we often see, however, are organizations making multiple attempts to improve case management but achieving mixed results due to leadership, staffing, performance and technical limitations. In our experience, when a successful performance improvement initiative is implemented a high-performing case management organization can expect a 4:1 return on investment (ROI) by capturing margins associated with additional capacity, charge capture, reduced utilization and better clinical outcomes. A HIGH PERFORMING CASE MANAGEMENT ORGANIZATION CAN EXPECT A 4:1 ROI On the vanguard of thought. The future of healthcare requires nothing less.
WHAT DOES IT TAKE TO SEE THIS TYPE OF ROI? A PRIMARY COMPONENT IS SHARED FOCUS AND ALIGNMENT OF EFFORT BETWEEN THE CASE MANAGEMENT ORGANIZATION AND THE CFO, CMO AND CNO. This collaborative approach leads to significantly improved performance on a critical array of capabilities, from quality of care to clinical variation management to revenue cycle results. A leadership structure and performance measurement system that empowers case managers and supports shared accountability between clinical and financial leadership can be transformative. The Power of a High-Performing Case Management Organization Investing in acute case management and standardization of care processes can drive consistent positive impact on clinical quality and lead to substantial financial benefits to the health system, including: Decreased length of stay (LOS) through improved discharge planning Increased capacity in the Intensive Care Unit (ICU) and Operating Room (OR) Decreased clinical practice variation Reduction in clinical denials Fewer off-quality events and avoidable complications More efficient patient throughput and a better patient experience Fewer unnecessary admissions and preventable readmissions Reduced cost of care through more efficient resource utilization Page 1
Achieving the full range of potential benefits has proven elusive to most organizations. There has been a seemingly endless cycle of performance improvement efforts aimed at case management each making incremental improvements but few creating impactful, sustainable change. Capturing the majority of these benefits requires a unified oversight structure that supports highly trained clinical case managers, empowered to transition each patient through the acute hospital process to maximize both clinical outcomes and system reimbursement. The following six requirements must be firmly established to advance the case management organization as described above: 1 ADAPTIVE LEADERSHIP AND UNIFIED OVERSIGHT Critical to performance improvement is an adaptive case management leadership model that: z Establishes a Director of Case Management with accountability for both case management and social work; z Ensures case managers and social workers are empowered to perform at top of licensure and maintain clinical and operational excellence; z Supports the strategic direction and growth of the CM organization within and across the system; and z Balances performance directives to achieve clinical and financial objectives of the health system. When combined with a unified oversight structure between the CNO, CMO and CFO, and shared accountability for clinical and financial goals, the CM organization can achieve target levels of performance. 2 100% PLAN OF CARE AND DISCHARGE PLANNING All patients should have a plan of care with an aligned expected discharge plan developed by an integrated care team. The care team should include physicians, nurses and other clinical professionals, and be led by the case manager who is responsible for revising the plan as needed and actively managing the plan through transition and discharge. Ensuring 100% of patients are assigned to a case manager and have a plan of care upon admission requires a high level of discipline that can only be achieved through appropriate staffing, administrative support and data management. For example, organizations often have greater success with plan of care execution when they staff case managers to the Emergency Department (ED) to participate in the initial screening process and ensure patients are receiving appropriate level of care. Page 2
3 PHYSICIAN ADVISOR OF CASE MANAGEMENT When partnered effectively with an adaptive CM organization, the physician advisor can assist the case manager to decrease medical necessity denials by supporting secondary reviews and utilization management, improve throughput and patient transition with more accurate guidance on patient status and maximize attending physician engagement. It is critical that the physician advisor is firmly anchored within the physician leadership structure of the organization, with appropriate authority and accountability, to be effective in his/her role. Too often, the physician advisor is only a part-time role with no true authority, resulting in only limited, informal influence and minimal impact. 4 INTEGRATED UTILIZATION MANAGEMENT (UM) More often than not, UM is a separate and distinct responsibility divorced from the CM organization. Organizations that support a hybrid model, where the case manager is directly responsible for both patient UM and patient transition, tend to maximize associated patient reimbursement. In some cases, an effective interim alternative is to have UM and case managers report to the same CM leadership, until CM staffing and training capabilities are at the required level to support a true hybrid model. 5 INTERDISCIPLINARY ROUNDING (IDR) Daily rounding that includes physicians, bedside nursing, social work and ancillary support, with the case manager acting as point, can optimize patient outcomes and minimize avoidable days. A daily, facilitated discussion that includes the anticipated discharge date of each patient is critical to confirm accurate patient status, effectively transition the patient through the acute care process and ensure appropriate utilization of acute care resources. 6 REAL-TIME REPORTING AND ACCURATE DATA-DRIVEN INSIGHTS The ability to leverage existing technology capabilities such as UM reports, patient status and expected LOS in real time can enhance case managers decisionmaking capability aided by accurate, data-driven insights. Embedding performance measurement into day-to-day activities through regularly produced dashboards and information systems will ensure ongoing monitoring of progress and documentation of benefits, and provide visibility that allows the case manager to intervene in stalled efforts or troubleshoot as necessary. Identifying shortfalls against goals and evaluating opportunities for the next wave of improvement will help to build the culture and accountability required for continuous improvement. Page 3
AN INTEGRATED VIEW OF PERFORMANCE Drives Clinical and Financial Returns A performance measurement system that defines key metrics, targets and accountabilities will go a long way toward advancing performance. It is worth asking, how are we currently performing across these key areas? Have we defined and articulated required performance levels and a timeframe for achieving them? Key dashboard metrics include: Clinical Denials Bed Utilization Cost per Discharge Avoidable Readmissions Length of Stay Hospital Acquired Conditions Late Day Discharges Historically, the responsibility of performing against each of these metrics has been distributed across multiple departments with differing leadership. For example, the CFO has been traditionally focused on clinical denials and cost per discharge; the CNO and COO on length of stay, bed utilization and transition management; and the CMO on hospital acquired conditions and avoidable readmissions. With such dispersed accountability, it is difficult to achieve an aggressive performance target around a key metric such as reducing cost per discharge. In contrast, a high performing case management organization can be an effective lever to directly impact cost per case. With the appropriate organizational structure, adaptive leadership model and performance measurement system in place, the following outcomes are within reach: z Operating margins can be steadily improved by: { Actively reducing clinical denials and concurrently maximizing reimbursement; { Managing capacity of existing beds; and { Streamlining episodes of care. z Avoidable readmissions can be reduced, while simultaneously decreasing wait times and diversions through: { Proactive admissions and discharge planning; { Active transition management; and { Family and care services engagement. z Cost per case can be lowered by: { Optimizing clinical utilization through varying clinical and support staff mix; { Top of license performance; and { Improving clinical outcomes. UNCERTAINTY IN HEALTHCARE HAS BECOME THE NORM, with regulatory and market pressures impacting margins and a system s ability to provide high quality care at a reasonable cost. If invested in appropriately, case management can be a valuable strategic lever to drive clinical and financial returns and effectively position the health system within an increasingly competitive market. Page 4
About the Authors Loren Mann Director 312.479.8438 lmann@chartis.com Loren Mann is a Director with The Chartis Group and a leader in the Performance practice. Mr. Mann has more than 15 years of healthcare experience and has served as an enterpriselevel strategic advisor to leading academic medical centers, integrated health systems, cancer centers and large community systems. Mr. Mann has led numerous clinical transformation and performance improvement engagements encompassing all aspects of performance including organizational strategy, leadership alignment, redesign of care delivery and operations, change management and implementation ensuring sustainable results in both clinical and bottom-line impact. Mark Werner, MD Director Clinical Consulting and Chartis Physician Leadership Institute 540.520.4161 mwerner@chartis.com Mark J. Werner, MD, CPE, FAAPL is a Director with The Chartis Group leading Clinical Consulting, the Chartis Physician Leadership Institute and our work with the physician segment. In this role, Dr. Werner leads clinical consulting efforts across the firm focusing on: enterprise physician alignment and leadership, medical group performance, adoption and change management, performance innovation, population health, provider-payor relationships and the translation of strategy into clinical operations. Cynthia Bailey Manager, Chartis Physician Leadership Institute 908.723.0712 cbailey@chartis.com Cynthia Bailey manages the Chartis Physician Leadership Institute and is a member of the firm s Performance practice. Ms. Bailey has more than 15 years of healthcare experience including strategy and operations consulting, sales and business development, and public health policy and communications. Page 5
About The Chartis Group The Chartis Group (Chartis) provides comprehensive advisory services and analytics to the healthcare industry. With an unparalleled depth of expertise in strategic planning, performance excellence, informatics and technology, and health analytics, Chartis helps leading academic medical centers, integrated delivery networks, children s hospitals and healthcare service organizations achieve transformative results. Chartis has offices in Atlanta, Boston, Chicago, New York, Minneapolis and San Francisco. For more information, visit www.chartis.com. Atlanta Boston Chicago Minneapolis New York San Francisco 2018 The Chartis Group, LLC. All rights reserved. This content draws on the research and experience of Chartis consultants and other sources. It is for general information purposes only and should not be used as a substitute for consultation with professional advisors.