Creating Data-driven - AAHAM Western Region...Data-driven performance improvement Clinical process of care (Core Measures) Transparency Safety and mortality (HACs) Delay avoidance

1 ©2014 Conifer Health Solutions, LLC. All Rights Reserved.

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

Data

Information

Knowledge

Annual National Institute

October 16, 2014


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

Objectives


“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 ‘Right Care, Right Setting, Right Time’

Clinical Revenue Cycle

Clinical Business Management

Hospital Case Management (HCM)


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

Challenged Programs:

• Access to Data

• IS Data Integrity

• Effective Reporting Tools

• Knowledge/Skill

• Day-to-Day Focused


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

HCM Data


“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?’”

- Don Berwick, MD, MPP

Former Administrator, Centers for Medicare and Medicaid Services

(CMS)

President Emeritus and Senior Fellow, Institute for Healthcare

Improvement (IHI)


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

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’

HCM Improved Clinical Revenue Cycle Outcomes


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

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.


• 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

HCM Scorecard


HCM Program Scorecard SAMPLE


HCM Analytics Framework

Fact-Based Decision

Making and Alignment of Resource Use

Information

Needs Assessed & Identified

1

Future State Design &

Build

2

Sustain & Optimize

3

Analytics and

Reporting

4


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

• Data sources: Case Management System(s)

ADT/EMR

Other organizational applications


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

• Access to data: Security

Timeliness

• Data integrity

• Lack of clinical analyst support



Fact-Based Decision


Information


1


Build

2

Sustain & Optimize

3

Analytics and

Reporting

4


• 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

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


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.

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)


Example Data Dictionary: Avoidable Delays (AD)

Data Field Name Screen/Tab

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



Fact-Based Decision


Information


1


Build

2

Sustain & Optimize

3

Analytics and

Reporting

4


• 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

3. HCM Auditor & Clinical Data Management


20



Fact-Based Decision


Information


1


Build

2

Sustain & Optimize

3

Analytics and

Reporting

4


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


• 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

Common HCM Analytics & Reporting Challenges


• Customized reports and dashboards

• Increases trust

Reports: Advances Accuracy and Meaningfulness

• Eases the collection, maintenance, and analysis of information

• Harnesses expertise of HCM clinicians and analytic staff

Analysis: Ensures Conclusions are Valid

• Efficiencies and success

• Progress related to strategic objectives and action plans

• Competitive performance

• Ability to respond rapidly to changing needs and challenges

Data Review: Assesses for …

• Deployed to departments, teams, and organization

Findings: Translates Into Improvement Priorities

High Quality Data for Accountability


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

• 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”


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

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


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

Promote a culture of enhanced transparency, true

quality care, service, and transformation


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

Target >4 Days: 25% (TBD) Target >10 Days: 6% (TBD)

115

120

125

130

135

140

145

150

0%

5%

10%

15%

20%

25%

30%

35%

40%

Acu

te IP

Ce

nsu

s

% A

cute

Cas

es

Exce

ed

ing

4 o

r 1

0 D

ays

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

Acute LOS Flash


Knowledge = Improvement = Success

HCM Value

Revenue Increase & Decrease Avoidance; Expense Decrease; Compliance Risk & Penalty Avoidance

Data Governance and Management

Effective Decision-Making, Improvement

and Compliance

HCM Optimization – Organizational, Clinical, Financial


It’s National Case Management Week!

CMSA

ACMA


Questions

Contact Information:

Lana Cabral, RN, BSN, MSM, CMAC, CRCR Senior Director, Case Management Services

Conifer Health Solutions Email: [email protected]

Michele Szymborski, CPHQ, CSHA Manager, Case Management Services

Conifer Health Solutions Email: [email protected]

https://mail.etenet.com/owa/redir.aspx?C=eb722330d5f245ada5dd8b391ed95a6d&URL=mailto:[email protected]

mailto:[email protected]

Appendices


HCM KPI Definitions

33


HCM KPI Definitions

34


• 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

HCM - Making the Business Case


• 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

HCM - Making the Business Case (cont’d)

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec <Month Year> <<Year>>

Metric Month Month Month Month Month Month Month Month Month Month Month Month YTD Actual Annual Target

Volume, Acute IP ↑

Vol, Acute IP MC ↑

CMI, Acute IP ↑

Volume, OBS ↓ or ↑

Volume, OIB ↓

% OBS & OIB of Total Acute IP Vol ↓ or ↑

ALOS, Acute IP ↓

ALOS, Acute IP MC ↓

ALOS, OBS (Hrs) ↓

Readmissions, MC Same Hosp ↓

Readmissions, MC Any Hosp ↓

Concurrent Denials Incidence ↓

Concurrent Appeals Incidence ↑

Concurrent Appeals% Successful ↑

Initial Reviews, MC % Completed ↑

MC Code 44s Incidence ↓

MC Provider Liable Claims Incidence ↓

OBS Changed to IP Incidence ↑

ADD: Hospital Incidence ↓

ADD: Provider Incidence ↓

ADD: Community Incidence ↓

ADD: Hospital Top Reasons ↓

ADD: Provider Top Reasons ↓

ADD: Community Top Reasons ↓

Red Red OP=Outpatient

Yellow OBS=Observation

Green

Results are not trending to meet the established annual target; †= Positive Improvement Trend

Results are inconsistent and may not meet the established annual target; †= Positive Improvement Trend

Results are on track to meet annual target

IP=Inpatient

OIB=OP in a bed

Data Source

Expected

Performance

ADD=Avoidable & Denied Day barriers/variances

Status Key

Acute=Excludes IP Rehab,

Hospice, etc & Well Mom/Baby

MC=Medicare

Baseline

% Variance

to Target

Hospital Case Management Summary Report

Hospital: <<name>> Realization Start Date: <<date>>

©2014 Conifer Health Solutions, Inc. Page 1 Hospital Summary Report

Data Source

Expected

Performance Baseline

% Variance

to Target



Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Data Analysis: Overall performance analysis addressing the inter-relationship of the above metrics

This Month's Variance Analysis on Metrics with Yellow & RED Status

Corrective Action Plan: Tactical plan to remedy variances with measurable and specific expected outcomes and timeframes


Data Source

Expected

Performance Baseline

% Variance

to Target



ADD: Community Top Reasons (Process)

ADD: Community Incidence (Process)

ADD: Hospital Top Reasons (Process)

ADD: Provider Top Reasons (Process)

OBS Changed to IP Incidence (Process)

ADD: Hospital Incidence (Process)

ADD: Provider Incidence (Process)

Initial Reviews, MC % Completed (Process)

MC Code 44s Incidence (Process)

MC Provider Liable Claims Incidence (Process)

Readmissions, MC Any Hosp (Outcome)

Concurrent Appeals Incidence (Process)

Concurrent Appeals% Successful (Process)

Readmissions, MC Same Hosp (Outcome)

ALOS, OBS (Hrs) (Outcome)

Volume, OIB (Outcome)

Metric, (Metric Type) & Target Definitions

Volume, Acute IP (Outcome)

Vol, Acute IP MC (outcome)

CMI, Acute IP (Outcome)

Volume, OBS (Outcome)

% OBS & OIB of Total Acute IP Vol (Outcome)

ALOS, Acute IP (Outcome)

ALOS, Acute IP MC (Outcome)

Concurrent Denials Incidence (Process)


Documents

Creating Data-driven - AAHAM Western Region...Data-driven performance improvement Clinical process of care (Core Measures) Transparency Safety and mortality (HACs) Delay avoidance