Annual National Institute
Creating Data‐driven
Strategies to Improve
Hospital Outcomes
A Case Manager’s Guide
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Data
Information
Knowledge
October 16, 2014

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
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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
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‘Right Care, Right Setting, Right Time’
Clinical Revenue Cycle
Clinical Business Management

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
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Challenged Programs:
• Access to Data
• IS Data Integrity
• Effective Reporting Tools
• Knowledge/Skill
• Day‐to‐Day Focused

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
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“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?’”
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‐ Don Berwick, MD, MPP
Former Administrator, Centers for
Medicare and Medicaid Services
(CMS)
President Emeritus and Senior
Fellow, Institute for Healthcare
Improvement (IHI)

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 $$ of filling
the bed
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Readmission
(Unplanned)
Reduction
CM or SW in the ED intervenes, sets up services
and facilitates release of a Medicare heart failure
patient recently hospitalized; Readmission
prevented; Readmission rate improves, $$
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 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
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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.

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
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HCM Program Scorecard SAMPLE
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HCM Analytics Framework
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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

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
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• 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
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• Access to data:
 Security
 Timeliness
• Data integrity
• Lack of clinical analyst
support

HCM Analytics Framework
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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

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
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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.
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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
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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

HCM Analytics Framework
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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

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
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20

HCM Analytics Framework
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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

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
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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
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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
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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
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• 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
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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
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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
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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

Knowledge = Improvement = Success
HCM Value
Revenue Increase &
Decrease Avoidance;
Expense Decrease;
Compliance Risk &
Penalty Avoidance
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Data Governance and
Management
Effective Decision‐
Making, Improvement
and Compliance
HCM Optimization – Organizational, Clinical, Financial

It’s National Case Management Week!
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CMSA
ACMA

Questions
Contact Information:
Lana Cabral, RN, BSN, MSM, CMAC, CRCR
Senior Director, Case Management Services
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Conifer Health Solutions
Email: lana.cabral@coniferhealth.com
Michele Szymborski, CPHQ, CSHA
Manager, Case Management Services
Conifer Health Solutions
Email: michele.szymborski@coniferhealth.com

Appendices

HCM KPI Definitions
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HCM KPI Definitions
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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
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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
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