Leveraging data for case management practice

Data is an essential tool in understanding the patient population that will guide the focus of your program. Both internal metrics and community/public health data will provide strategic focus to case management practices. Data can offer clarity about the specific populations that may need case management services.

Data relevant to understanding patient populations that need case management include:

• Public health data:
  • Encourages focus
  • Identifies unmet needs
  • Provides information about the health of the community
• Hospital data
  • Ensures everyone is on the same page
  • Provides a baseline for improvement
  • Supports decisions about priorities

The following metrics will provide insights into the community and the type of case management interventions needed, from disease management to addressing social determinants of health.

• Public health:
  • Top diagnosis-related groups (DRG) in the community
  • Average age of the community
  • Health practices in the region (e.g., immunizations, smoking)
• Health system data:
  • Readmission rates by DRG
  • Hospital length of stay by DRG and payer
  • Emergency department visits by primary care provider
  • Denial rates by medical necessity
  • Case-mix index (to better understand the acuity of the patient population and possible need for catastrophic care programs)
  • Patient satisfaction scores (note that patient engagement supports better outcomes)
  • Disposition rates—where are the patients all going?

It is essential to understand the progress being made with the patient population as well as the organization’s health. The Quality Realm Core Measures in the inpatient setting and Healthcare Effectiveness Data and Information Set (HEDIS®) measures in ambulatory arenas help the teams understand the organization’s ability to maintain quality of care and medical outcomes.

Core measures are standardized best practices designed to improve patient care. U.S. hospitals must also submit performance measures to The Joint Commission and Centers for Medicare & Medicaid Services; additionally, performance on these measures is publicly reported.

HEDIS is a tool that more than 90% of U.S. health plans use to measure performance on important dimensions of care and service. Altogether, HEDIS consists of 81 measures across five domains of care.

The profession of case management is all about influencing outcomes. No other discipline within the healthcare community manages to position themselves to improve and maximize reimbursement, manage or reduce cost, and avoid penalties. Because case management is a synergistic practice (working with RNs, physicians, and social workers), it offers a formula for success.

A good case management program, and its leadership, understands and leverages data to inform practice and improvement, communicates trends that demonstrate its knowledge, and motivates and engages teams to act. Data must be transparent, user-friendly, organized, and informative.

Strong case management leaders live by this formula: Stay ahead of the information, communicate with knowledge and confidence, and use data as a call to action and engagement.

Editor's note: For more infomation, see Care Transitions in Case Managment.