Executive Summary

The 7 Key Components of an Effective Case Management Methodology

Introduction: The Overlooked Value of Case Management

Case management is being overlooked as a care delivery framework with the potential to relieve three of the most significant pressures facing hospital leaders – to improve clinical quality, to increase operational efficiency and to improve profitability. Furthermore, case management capabilities are underutilized in the healthcare delivery organizations and areas that need its value the most.

The pressure to improve clinical quality is increasing in intensity from the federal government, from payers and purchasers, from quality standards organizations and from patients themselves. We see this in the steep rise in regulatory compliance demands, pay for performance (P4P) contracts, clinical quality improvement initiatives and public reporting of clinical quality measures.

The pressure to increase operational efficiency is also coming from many of these same groups, as well as from the sharp increase in competitiveness in the marketplace. We see this in the increased competitiveness in terms of speed of care delivery, improvement of the patient experience, delivering more care services despite the shortage of physicians and nurses, and in the drive to differentiate our services.

The pressure to improve profitability is ever-present as hospitals and other healthcare delivery organizations must answer to investors, communities and governmental agencies. We see this in the rise in reimbursement pressures, cost and waste reduction pressures, productivity and efficiency pressures, the push to develop and implement new revenue streams and alternative care delivery models, and in the increasing demand for uncompensated care.

A recent study published in Nursing Economic$ indicated that case management is practiced by only 61% of non-federal acute care hospitals in the U.S. This study also showed a strong correlation between the existence of case management practices and a number of positive measures of business success.

These are only correlations and not necessarily causal relationships. The purpose of this paper, however, is to illustrate a number of ways in which hospital case management can and does produce clinical, operational and financial benefits for the organization.

Achieving Quality, Efficiency and Profitability

Not only is hospital case management being underutilized, but also, like management in general, there is a right way and a wrong way to conduct this practice.

Sixty years ago, W. Edwards Deming taught us that traditional management practices attempted to “inspect in” quality, efficiency and profitability. By this, he meant that organizations were doing things backwards. They were buying resources, hiring workers and performing processes to deliver results, and only then were they checking to see if the results were of good quality. Under such practices, rework and waste are high.

In healthcare, this manifests itself in a number of ways. For instance, utilization reviews are used to check and correct clinical quality problems after they occur. Disciplinary measures are used to attempt to fix operational problems after they happen. And claims resubmissions are used to reverse reimbursement denials. Millions of dollars are spent on patches to fix these problems and millions more are wasted on rework, reprocessing, pain, suffering and even death.

Examples of this in healthcare include evidence-based clinical guidelines and protocols designed using team collaboration. Processes and procedures are designed using Lean and Six Sigma practices. And intelligent revenue cycle management systems are used to improve reimbursement rates by proactively alerting management to potential denials.

These measures to manage organizations using intelligent design have done a great deal to predict and prevent problems in healthcare delivery organizations. But there are two other dimensions to doing things the right way that have been overlooked.

The second additional dimension is the evolution of the people, processes and technologies to further improve their performance and make it easier, faster and better to do things the right way. This is where a sophisticated case management methodology comes in.

Read the entire study.