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Creating Data-driven Strategies to Improve Hospital Outcomes: A Case Manager's Guide

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Creating Data-driven Strategies to Improve Hospital Outcomes: A Case Manager's Guide

  1. 1. Annual National Institute Creating Data‐driven Strategies to Improve Hospital Outcomes A Case Manager’s Guide 1 ©2014 Conifer Health Solutions, LLC. All Rights Reserved. Data Information Knowledge October 16, 2014
  2. 2. Objectives 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 2 ©2014 Conifer Health Solutions, LLC. All Rights Reserved.
  3. 3. Hospital Case Management (HCM) “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 3 ©2014 Conifer Health Solutions, LLC. All Rights Reserved. ‘Right Care, Right Setting, Right Time’ Clinical Revenue Cycle Clinical Business Management
  4. 4. HCM Program Characteristics 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 4 ©2014 Conifer Health Solutions, LLC. All Rights Reserved. Challenged Programs: • Access to Data • IS Data Integrity • Effective Reporting Tools • Knowledge/Skill • Day‐to‐Day Focused
  5. 5. HCM Data 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 5 ©2014 Conifer Health Solutions, LLC. All Rights Reserved.
  6. 6. “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?’” 6 ©2014 Conifer Health Solutions, LLC. All Rights Reserved. ‐ Don Berwick, MD, MPP Former Administrator, Centers for Medicare and Medicaid Services (CMS) President Emeritus and Senior Fellow, Institute for Healthcare Improvement (IHI)
  7. 7. HCM Improved Clinical Revenue Cycle Outcomes Revenue Increase Revenue Decrease Avoidance Capacity Management Length of stay/Throughput Management to improve bed capacity and patient volumes (when unit capacity is an issue); Add the value $$ of filling the bed 7 ©2014 Conifer Health Solutions, LLC. All Rights Reserved. Readmission (Unplanned) Reduction CM or SW in the ED intervenes, sets up services and facilitates release of a Medicare heart failure patient recently hospitalized; Readmission prevented; Readmission rate improves, $$ 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 $$ denials Concurrent Appeal Clinical appeal managed prior to claim and when successful, retro denials management avoided “X”$$ Expense Decrease Compliance Risk/Penalty Avoidance Resource Utilization/ Efficiency Orders for duplicative or unrelated tests are ‘caught’ and cancelled reducing 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’
  8. 8. HCM Improved Clinical Quality Outcomes 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 8 ©2014 Conifer Health Solutions, LLC. All Rights Reserved. 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.
  9. 9. HCM Scorecard • 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 9 ©2014 Conifer Health Solutions, LLC. All Rights Reserved.
  10. 10. HCM Program Scorecard SAMPLE 10 ©2014 Conifer Health Solutions, LLC. All Rights Reserved.
  11. 11. HCM Analytics Framework 11 ©2014 Conifer Health Solutions, LLC. All Rights Reserved. Information Needs Assessed & Identified 1 Fact‐Based Decision Making and Alignment of Resource Use Future State Design & Build 2 Sustain & Optimize 3 Analytics and Reporting 4
  12. 12. 1. Information Needs Assessment • Identify data needs:  Mandatory  Strategic initiatives  Compelled to do  Performance improvement: o Clinical o Financial o Operations  Internal reporting: o Utilization Review Committee o Quality Management Committee o Corporate Reporting, as applicable 12 ©2014 Conifer Health Solutions, LLC. All Rights Reserved. • Data sources:  Case Management System(s)  ADT/EMR  Other organizational applications
  13. 13. Common CM Data Management Issues • 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 13 ©2014 Conifer Health Solutions, LLC. All Rights Reserved. • Access to data:  Security  Timeliness • Data integrity • Lack of clinical analyst support
  14. 14. HCM Analytics Framework 14 ©2014 Conifer Health Solutions, LLC. All Rights Reserved. Information Needs Assessed & Identified 1 Fact‐Based Decision Making and Alignment of Resource Use Future State Design & Build 2 Sustain & Optimize 3 Analytics and Reporting 4
  15. 15. 2. Future State Design Goal: Get the right information to the right people at the right time in the right amount and in the right format • 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 15 ©2014 Conifer Health Solutions, LLC. All Rights Reserved.
  16. 16. 2. Future State Build Get the right information to the right people at the right time in the right amount and in the right format. 16 ©2014 Conifer Health Solutions, LLC. All Rights Reserved. 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)
  17. 17. Example Data Dictionary: Avoidable Delays (AD) Data Field Name Screen/Tab 17 ©2014 Conifer Health Solutions, LLC. All Rights Reserved. Dictionary Type 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 Employees The person whose professional judgment determined the Avoidable Day/Delay R as applicable Hospital DRG AD Home Page Interfaced Once 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 Departments Select the hospital department attributed with the AD, as applicable R as applicable Physician Attributed Cause Providers Select the provider/physician attributed with the AD, as applicable R as applicable
  18. 18. HCM Analytics Framework 18 ©2014 Conifer Health Solutions, LLC. All Rights Reserved. Information Needs Assessed & Identified 1 Fact‐Based Decision Making and Alignment of Resource Use Future State Design & Build 2 Sustain & Optimize 3 Analytics and Reporting 4
  19. 19. 3. HCM Auditor & Clinical Data Management • 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 19 ©2014 Conifer Health Solutions, LLC. All Rights Reserved.
  20. 20. 20 ©2014 Conifer Health Solutions, LLC. All Rights Reserved. 20
  21. 21. HCM Analytics Framework 21 ©2014 Conifer Health Solutions, LLC. All Rights Reserved. Information Needs Assessed & Identified 1 Fact‐Based Decision Making and Alignment of Resource Use Future State Design & Build 2 Sustain & Optimize 3 Analytics and Reporting 4
  22. 22. 4. Key Capabilities of HCM Analytics & 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 22 ©2014 Conifer Health Solutions, LLC. All Rights Reserved.
  23. 23. Common HCM Analytics & Reporting Challenges • 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 23 ©2014 Conifer Health Solutions, LLC. All Rights Reserved.
  24. 24. High Quality Data for Accountability Reports: Advances Accuracy and Meaningfulness • Customized reports and dashboards • Increases trust Analysis: Ensures Conclusions are Valid • Eases the collection, maintenance, and analysis of information • Harnesses expertise of HCM clinicians and analytic staff Data Review: Assesses for … • Efficiencies and success • Progress related to strategic objectives and action plans • Competitive performance • Ability to respond rapidly to changing needs and challenges Findings: Translates Into Improvement Priorities • Deployed to departments, teams, and organization 24 ©2014 Conifer Health Solutions, LLC. All Rights Reserved.
  25. 25. Develop and Foster Key Partnerships • 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 25 ©2014 Conifer Health Solutions, LLC. All Rights Reserved. • 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”
  26. 26. Develop Team‐Based Approach/Interventions… To Improve Patient and Organizational Outcomes Interdisciplinary Review of ‘Actionable Data’/Audit Risk Areas: • PEPPER and other benchmarking data • Avoidable delay tracking 26 ©2014 Conifer Health Solutions, LLC. All Rights Reserved. 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 Board Include HCM in organizational quality and performance improvement activities/work teams
  27. 27. Influence Behavior with Data • 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 27 ©2014 Conifer Health Solutions, LLC. All Rights Reserved. Promote a culture of enhanced transparency, true quality care, service, and transformation
  28. 28. Employ Tactical Efforts – Example: LOS Daily Flash 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 28 ©2014 Conifer Health Solutions, LLC. All Rights Reserved. Acute LOS Flash Target >4 Days: 25% (TBD) Target >10 Days: 6% (TBD) 150 145 140 135 130 125 120 115 40% 35% 30% 25% 20% 15% 10% 5% 0% Acute IP Census % Acute Cases Exceeding 4 or 10 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
  29. 29. Knowledge = Improvement = Success HCM Value Revenue Increase & Decrease Avoidance; Expense Decrease; Compliance Risk & Penalty Avoidance 29 ©2014 Conifer Health Solutions, LLC. All Rights Reserved. Data Governance and Management Effective Decision‐ Making, Improvement and Compliance HCM Optimization – Organizational, Clinical, Financial
  30. 30. It’s National Case Management Week! 30 ©2014 Conifer Health Solutions, LLC. All Rights Reserved. CMSA ACMA
  31. 31. Questions Contact Information: Lana Cabral, RN, BSN, MSM, CMAC, CRCR Senior Director, Case Management Services 31 ©2014 Conifer Health Solutions, LLC. All Rights Reserved. Conifer Health Solutions Email: lana.cabral@coniferhealth.com Michele Szymborski, CPHQ, CSHA Manager, Case Management Services Conifer Health Solutions Email: michele.szymborski@coniferhealth.com
  32. 32. Appendices
  33. 33. HCM KPI Definitions 33 ©2014 Conifer Health Solutions, LLC. All Rights Reserved. 33
  34. 34. HCM KPI Definitions 34 ©2014 Conifer Health Solutions, LLC. All Rights Reserved. 34
  35. 35. HCM ‐ Making the Business Case • 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 35 ©2014 Conifer Health Solutions, LLC. All Rights Reserved.
  36. 36. HCM ‐ Making the Business Case (cont’d) • 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 ; either Reducing Expense or creating an open bed to be filled‐Revenue Increase 36 ©2014 Conifer Health Solutions, LLC. All Rights Reserved.

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