Case Management: Returning Value to Your Bottom Line

In today’s healthcare environment, an efficient and effective case management (CM) department is a necessity to maximize outcomes in the realms of patient satisfaction, physician satisfaction and finance. But, how can you know if your department is returning value to your bottom line? Since the role of case management is increasing daily, we can help you gauge how successful your department is currently. With these five key responsibilities or processes below, we encourage you to assess your current case management department and discover what you can do to drive your facility towards greater success.

Medical Necessity and Patient Status

Whether your facility utilizes a CM model that has utilization review separated or not, accurately managing patient status (inpatient vs. observation) is one of the first key responsibilities for a department. Tools and team members’ locations will vary from facility to facility, but a standard process for managing patient status must be in place.  If your facility is encountering any of these types of scenarios, it may be worth taking a deeper dive to understand the breakdowns. These breakdowns can include frequent inpatient or observation status changes, increased utilization of Condition Code 44 or W2, and denials from payers for disagreement in patient status thus resulting in reduced payment.

Patient Care Coordination

Case management departments that assist their facilities in achieving top-tier results are becoming more involved in patient care coordination.  What exactly does this mean? With this practice, the case manager assists in driving care forward and reducing variation in the care being provided. This can mean they are leading discussions on medication utilization, diet advancement, level of care monitoring (ICU vs Stepdown vs Med/Surg), weaning protocols, etc. Their actions are the key steps to ensuring each patient is receiving the right care at the right time in the right setting with the right resources.

Transitions in Care

Continuing the activities of care coordination, establishing plans and ensuring they are appropriate when a patient transitions out of the hospital is paramount.  It is much more than what has been called “discharge planning” for years.  We can no longer be successful by just planning for the patient to be discharged from our facility.  We must develop solid transition plans that the patient understands so they experience success. Achieving these steps will encourage greater patient adoption and success of their plans, which in turn can lead to reduced readmissions and lower cost in overall care.

Avoidable Delay Management and Capture

When one of the first three processes above is not functioning well, avoidable delays leading to increased costs or resources need to be captured.  It is a key function of case management to be aware of these issues and capture them in an actionable method for leadership.  Consistent capture of avoidable delays is a powerful mechanism to ensure effective and efficient care delivery.

Denial Management

A high performing case management program will assist in proactive denial management. But in today’s payer environment, it won’t make denials disappear. To close the loop on this key responsibility, it is important to have your department involved in denial management as it specifically relates to their work. Case management departments should have a close relationship with your facility’s revenue cycle operations to understand the impact of their work on the hospital’s bottom line.

A successful case management program is the cornerstone for your hospital or health system to successfully move forward. In order to return value to your bottom line, it’s vital that the five key responsibilities listed above be at the core of your case management department. If one of them is missing in your facility’s case management program today or is present but not producing the results you would like, QHR can help. Our clinical resource management solution can help your hospital improve operational efficiency while also reducing costs. Learn more about it here.

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