How case managers can engage in meaningful outcomes management

June 25, 2019

Medicare Web

I hear a frequent complaint from case managers across practice settings. The expanded emphasis on well-intended preemptive revenue cycle management ends up focusing on illusive metrics for the industry, such as geometric mean length of stay (GMLOS), hospital consumer assessment of healthcare providers and systems (HCAHPS), and readmission rates.

This reality occurs instead of looking at the unique factors for the specific organization that actually cause those metrics to be out of whack in the first place. Independent of practice setting, case managers are often left with the overwhelming task of waving their proverbial magic wands and ensuring unilateral attention to these issues. This assignment is not practical or realistic. These are interprofessional times that beg for collaborative approaches to identify and address a fresh generation of outcomes that ensure actionable accountability by key personnel. Given case managers’ wide lens of the client care process, they are in a prime position to lead this effort.

Powell and Tahan (2019) detail six categories that exemplify meaningful outcomes management for case management, as shown below. Useful outcomes must measure more information than simply numbers (e.g., number of readmissions, denials, length of stay). To be successful in the current industry, all outcomes must be intentionally chosen and speak to both numbers and potential explanations for why those numbers don’t meet the expected threshold.

Otherwise, these efforts cease to be helpful—becoming simply those items captured to validate a particular department standard or metric has been met. Today’s healthcare workforce is far too busy to engage in any activities that are anything less than purposeful. All outcomes should provide vested stakeholders with clear data that clearly informs why variances and issues are significant and useful toward enhancing organizational performance (Fink-Samnick, 2019, pg. 82).

They should lead to the development of actionable and strategic plans to evolve clear process changes. Only then can an organization effectively meet the combined mandates of attending to clinical, nonclinical, and fiscal priorities required by their SDoH populations. Meaningful outcomes management also ensures the organization’s financial sustainability for the long term.

Meaningful outcome management measures

Cost

Length of stay
Cost per case
Cost per diagnosis
Cost per encounter or visit

Utilization

Average number of labs, tests
Number of denials per unit, physician, program
Appeal conversion rate
Number of avoidable days (with reason)
Turnaround time on labs, procedure, tests, reports
Surgical delays, cancellations (with reason)

Transitional planning/throughput

Discharge delays (with reason)
Readmissions within 72 hours (with reason)
Turnaround time from emergency department to floor
Appropriateness of level of care
Amount of time to resolve if inappropriate
Effective/ineffective handoffs (with reason)

Clinical

Change from intravenous to oral medications
Morbidity complication rates
Medical or medication errors
Pain management

Care experience and satisfaction

Patient and family experience scores
Discharge planning processes (e.g., communications with case management)
Health perception
Quality of life
State of well-being

Variance/delay in care

Patient-/family-related variance (e.g., refusal of care, plan, facility)
System-related variance (e.g., equipment malfunction impact test completion)
Practitioner-related variance (e.g., medication error, delay in discharge)
Timely access to care (e.g., delay in consult by specialty provider)
Lack of availability of needed discharge resource (e.g., bed availability, pending Medicaid for homecare or placement)

References:

Fink-Samnick, E. (2019). Chapter 4: Care considerations to challenge ethical excellence, in The essential guide to interprofessional ethics in healthcare case management, pp. 67–97. Middleton, MA: HCPro.

Powell, S. K., & Tahan, H. M. (2019). Chapter 7: Quality management and outcomes evaluation in Case management: A practical guide for education and practice, 4th ed. pp. 214–246. Philadelphia, PA: Wolters Kluwer.

Editor’s note: This article is an excerpt from an HCPro book, The Social Determinants of Health: Case Management's Next Frontier, by Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP.