The Discipline of Value Based Case Management

by Stefani Daniels, Managing Partner
Published on Feb 01, 2017

Successful case management program leaders don’t float around aimlessly on the way to achievement. They have a plan, a routine, a series of steps that they engage in. They have a drive to achieve and thrive to acquire the program's target. Every leader must have a step-by-step plan to get where they want to be.

Despite today's tumultuous political uncertainty, there is no reason to think that changes in care delivery and payment models will cease.  The corporations, business owners and individuals who pay for healthcare services are demanding better quality, better outcomes, and lower costs.  Case management program leaders are not alone in asking their team, "how are we going to differentiate ourselves in a very competitive market to demonstrate that what we do brings value to our organization, our community and our patients."  

Some of the answers may lie in how the program director views the case management program.  Is it a compilation of several routine services that the hospital provides or is it a critical 'service line' that must be managed like a business. Does the entire case management team leverage its service line advantage to its multiple stakeholders?  Do the stakeholders really know what value the program brings to the organization?  Do members of the case management program itself know?  Creating an infrastructure around the key services offered by case management  (e.g.: care coordination, psychosocial services, utilization review, etc) which takes into account marketplace pressures, ensures that the leader has put the program into a position that maximizes its total value.  In the long term, well-run case management service lines help hospitals achieve the Triple Aim and possibly help ride out the financial storms that surround the hospital industry.

When the executive team and case management leaders view the case management program as an essential service line, the hospital is generally more efficient and effective than those that view case management programs as routine processes to discharge patients and comply with federal and state rules and regulations. Service line-focused case management programs are constantly restructuring, improving processes, exercising greater influence to achieve better clinical and financial outcomes and building value.

Organize for value

To get started, the executive sponsor and case management leader must understand the program's capabilities.  What is currently in place with regard to marketplace forces, resources, technology, relationships and knowledge. Some important concepts include:

1.  Know the marketplace. To get known for the excellence of your program, you need a strong brand message. One that is tight, compelling and easily recognizable. What is the case management program's unique value proposition in the hospital's current marketplace?  For example, if utilization review is under the case management umbrella, what demands are being placed on compliance and what value does UR bring to the table? How do the execs know? What is the organization's experience with payer denials?  What is being done in regard to denial prevention and what role does UR play...or should be playing? How is UR success being measured to demonstrate value?  It is critical that case management leadership understands the current market and the driving forces that impact the success of an effective program. 

2.  Build core competencies among program resources. Does the staff in each component of the case management program have access to the latest information about trends in their respective field? Are they exposed to educational opportunities to bring new ideas and strategies from other facilities?  For example, are the care coordinators motivated to innovate progression-of-care continuity in the hospital and through transitional care?  Are the care coordinators encouraged to explore innovation in care coordination? Do they understand coordination implies deliberately organizing patient care activities and sharing information among all of the participants on the patient's care team?  How has their practice changed to fulfill this responsibility? Are the UR specialists comfortable critiquing medical necessity documentation in order to effectively coach physicians? Do the psychosocial counselors help patients work through the emotions of a diagnosis, and provide counseling about the decisions that need to be made so that progression-of-care moves forward toward a timely transition? Are they able to quantify their contributions?  

3.  Form strategic relationships.  A successful case management program builds on relationships that extend beyond hospitalists and community attendings. They must tap into key resources within the community to build partnerships that benefit the patients and align goals. For example, can a transitional care program have ties to area employers, secondary schools and colleages to offer community based services that can generate revenue to cover the costs for the high risk patients being monitored by the Transitional team?

4.  Create the right infrastructure and processes.  Is the program structured and organized optimally to achieve expected goals?  We hear alot about care coordinator turnover;  is it because of faulty structure and operations that place burdensome expectations on the individual?  Closely examine the structure currently in place. Is it optimally designed to achieve the desired results?  Review  job descriptions and role expectations; attracting a variety of clinical disciplines to the program to broaden perspectives and approaches may prove to be a significant catalyst to fulfill program goals.  It means using available technology to identify patients who would benefit most from care coordination and generate measurable outcomes proving value.  While technology resources vary between small community hospitals and large academic teaching facilities, every hospital has some source of data that can be turned into information to help care coordinators, social counselors, and utilization reviewers. Leaders must pursue available resources and lobby for additional support as the transformation of the case management program shifts from a 'routine' program  to a strong service line that demonstrates objective value for the patients and the organization.