C O L L A B O R A T I V E C A S E M A N A G E M E N T

A View From the Field:

A CEO’s Perspective of Case Management
by Andrew B. Leeka

Over a decade ago, we started reading about expected cost-containment pressures on healthcare resources as the first wave of aging baby boomers
began their physical decline and refused to accept what previous generations saw as the natural aging process. Today, those pressures are
becoming a reality. In addition to mandatory requirements for seismic code renovations by 2013 (which includes a recent five-year extension) and
increases in the number of uninsured patients seeking treatment, California hospitals, in particular, now face regulatory demands for nurse-to-patient
ratios. These ratios pave the way for the nursing shortage to continue unabated and salaries for nurses to continue to climb. At the same time,
technology continues to push dramatic improvements in diagnostic capability, treatment and care, but also inflates the overall cost of healthcare.

With anticipation of the growing numbers of baby boomers entering
retirement age and ever-increasing numbers of uninsured patients, we
understand that a strong, vital and empowered case management function is
one of the most effective ways to reduce the waste of resources. Appropriate
and effective use of resources becomes critical as it encompasses both ethical
and clinically sound mechanisms to manage resources professionally.
Therefore, it becomes imperative for hospital survival that every patient receive
the most appropriate care with the best allotment of resources in the most
appropriate setting at the most appropriate time. The strategic approach to
accomplish this is to focus on four principles with case management services,
medical staff cooperation and staff education.
CASE MANAGEMENT HELPS ALLOCATE RESOURCES
Case managers focus on improving processes to reduce variability in care.
When processes are improved, quality of care improves and hence, financial
savings will follow. To improve our case management process, a multi-
disciplinary team involving hospital staff that has a stake in case
management completed an assessment of the case management
process and debuted a new model hospital-wide. The team included
representatives from the Pharmacy, Social Work, Dietary,
Respiratory, Nursing and Administration departments. The work
was supported by a physician steering committee.
Previously our case managers had been trained on a
utilization review model. The new model focuses on “care
coordination.” Case managers not only identify what
road blocks exist, but offer solutions to our physicians
to resolve and remove those road blocks. With
today’s case management model, everyone
understands that case managers need to
continually improve care plans to unveil
opportunities to reduce variability and
ultimately improve care – which helps the
bottom line and truly improves quality
of care. The process to introduce the
new model included education, in both classroom and practical settings, and
allowed our case management staff to develop more effective relationships
with physicians for better care coordination.
Our new Case Management Registered Nurse, Case Management Social
Worker and Case Management Coordinator (a clerical position) teams were
assigned units rather than patient populations in order to develop product-line
expertise and better ensure patient continuity of care. When patients transfer
between units, their clinical information moves with them to the new case
management team. Additionally, by assessing each patient within 48 hours of
admission onto a unit, we have found our case managers facilitate better
communication among all caregivers. “Weekend Watches” have been created
for each patient to ensure that items that are supposed to occur over the
weekend, do happen. These items could include transfers to a lower level of
care or discharge, which previously might have waited until Monday.
Our case managers have gained the support of our physicians, Chief of Staff,
Chief Nursing Officer, Chief Financial Officer and other patient-care
3
professionals throughout the hospital. That support from physicians and others
gets its foundation from several areas. One source is from the Chief of Staff’s
expectation that cooperation with case managers will occur. Additional support
starts with the hospital President and President’s Council who stand behind
hospital case managers with a zero tolerance for negative physician behavior.
By returning phone calls as promptly as possible and by paying attention to the
case manager findings, physicians support case managers.
Additionally, by setting their own length-of-stay goals, our case managers
have ownership, pride and accountability in the process. Thanks to their goal
setting, we have achieved a $4 million dollar savings in the first 18 months.
ETHICS, EFFICIENCY, ENFORCEMENT AND EDUCATION —
THE 4 PRINCIPLES OF OUR CASE MANAGEMENT FRAMEWORK
At Good Samaritan, we have found that as we build upon our successes in
case management, our patients are more satisfied, medical errors are
reduced, length of stay is reduced, processes are improved and our market
position becomes stronger, which again all lead to higher quality of care
and greater financial security. We refer to the framework for our case
management as the Four Es (Ethics, Efficiency, Enforcement, and
Education). It is depicted to the left as a triangle.
At the apex is Ethics, the galvanizing force for doctors, nurses
and other hospital staff members. There must be the highest
ethical standards for all cases that come to the hospital. The
Ethics Committee reviews and addresses situations referred
by case managers. Our Ethics Committee reviews cases in
a timely manner or in emergency sessions to uncover
opportunities appropriate to patient care plans. The
opportunities may include areas such as futile care,
and cases in which patient and family wishes
differ from a physician’s advice. As
opportunities are revealed, the Medical Staff
Executive Committee acts on the Ethics
Committee’s findings. When an ethics
situation calls for it, they provide
counseling sessions with physicians as a first step, and may move to the
removal of ER on-call privileges, or ultimately, revocation of staff privileges if
counseling is not followed by demonstrable improvement.
At the bottom left corner of the triangle is Efficiency. Efficiency is the ability
to track and compare severity-adjusted data to evaluate physician
performance objectively and identify outliers. In monitoring efficiency, we
benchmark against national standards as well as among physician peers to
best relate to and influence physicians who are trained to respond to timely,
accurate, and understandable data.
Enforcement is the bottom right supporting corner of the triangle. The
enforcement refers to continual compliance with the Medical Staff Bylaws. A
hospital should not embark on case management unless bylaws and policies
governing the medical staff have real teeth in them. As with any facility, we
found that a handful of physicians that fight the case management program
are those with the most consistent outliers. When challenged, other members
of the medical staff will watch and see if inappropriate behavior is ignored or is
(continued on page 7)
 C O L L A B O R A T I V E
The Way I See It: A CEO Perspective (continued from page 3)
dealt with in a fair and consistent manner. Physicians are no different from the
rest of us – change is difficult. However, continuous improvement and
therefore, change, is the rigor for a good case management program to be
successful.
Circulating through all aspects of the triangle is education – ongoing
education of physicians and case managers. Our case managers have
educational opportunities about appropriate patient progress, care planning
and documentation of problems. Our medical staff is educated about what
case management is: the case management process, goals and expectations of
physician participation in a successful program. Case management is care
coordination. It ensures consistent quality care to all patients, regardless of
Capturing Return on Investment for Case Management Services (continued from page 5)
VISIBILITY: THE BOTTOM LINE
Savings From Within
As case managers, our focus is appropriately outward – how can we improve
patients’ care, improve processes and increase the organization’s opportunity
for both cost saving and revenue. But, there is also opportunity when we look
inward at our department. The reduction of staff turnover in case management
is just such an opportunity. Community Health Network calculated what it
costs to bring in a new RN case manager and a new social work case manager.
The amounts are staggering: $45,962 and $38,970, respectively. These numbers
include everything — advertising the position, initial work by HR, checking
references, doing interviews, and the lengthy training and orientation
required before the new person can begin working independently. Clearly, it is
financially prudent to keep these professionals on staff as long as possible.
Community launched a multifaceted effort to retain case managers. A
significant budget was dedicated to newsletters, recognition events, and
various other retention efforts. Results demonstrated the return on this
investment. In one year, there was a 20 percent decrease in case management
turnover rate, which saved the network nearly $850,000.
Oncology Case Management Across the Continuum of Care (continued from page 6)
of the art activity, but also from opportunity to discuss her fears and
feelings about her new role as a cancer patient with other cancer patients
in the group.
INPATIENT ONCOLOGY DISCHARGE BOOK
The third component of collaboration, and a by-product of information
from the daily case management meetings, is the Inpatient Oncology
Discharge Book. The discharge book is kept in the outpatient Medical
Oncology Clinic team room and is used to track patient flow between the
inpatient and outpatient areas. Special attention is focused on outpatient
follow-up of patients hospitalized for chemotherapy, special procedures to
support treatment, complications associated with treatment and patients
diagnosed with cancer during hospitalization. The discharge book can be used
by all clinic staff to learn the reasons for admission, discharge dates, outpatient
clinic follow up dates, current telephone numbers, ongoing or planned
radiation therapy and special circumstances of discharge (shelters, personal
care homes, hospice, changes in environments for care and treatment plans).
The Inpatient Oncology Discharge Book also provides a record of whether
scheduled outpatient appointments are being kept and facilitates early
intervention if necessary. The written communication often serves as a
reference to clarify discrepancies in appointment scheduling thereby, helping
to keep patients on schedule for treatment and follow-up. A review of patients
C A S E M A N A G E M E N T
payor mix or ability to pay. We educate our medical teams to provide the same
standard of care for all patients.
Perhaps the biggest challenge is creating a new case management culture.
The responsibility to do this rests ultimately with the CEO and senior
management. In my view, the Four Es framework provides a context that
supports a proactive care coordination effort.
Andrew B. Leeka has been president/CEO of Good Samaritan Hospital (Los
Angeles) since 1996. He holds an MPH from the University of California Los
Angeles, an MBA from California State University Northridge and an MA in
Organizational Behavior from Philips Graduate Institute.
The Bottom Line
Community was successful is demonstrating to both their
administration and board very significant savings in five areas:
CDMP recovery, avoided delays, conversions recovery, appeals
recovery, and length of stay/DRGs. Their bottom-line total for the
last fiscal year: $5,750,000 recovered by case management. While the
revenue potential is dependent on the size of the hospital or health
system, being able to effectively collect and report such information
is a step toward recognition as a revenue-producing department
rather than an overhead department or cost center. And that is return
on investment.
Vickie Alexander Knight, is director of Case Management at Community
Hospitals of Indiana, in Indianapolis, IN. Her 30-year career in healthcare has
encompassed both the hospital and the payer side, home health, and consulting.
She holds an ADN from the University of Indianapolis and a BS in health
management from the College of St. Francis, Joliet, IL. She has served on the
Indiana Congress on HealthCare.
who were discharged from the inpatient oncology unit and who kept their
outpatient appointments to medical oncology clinic revealed 62 % compliance
during a 4-month period from May through August.
This venture in collaborative case management illustrates many benefits of
an integrated and collaborative case management system:
1. Shared comprehensive psycho-social assessments along the continuum
of care and the impact these assessments may have on the team
commitment to patient care.
2. A mechanism to address and track compliance issues and behavior,
allowing early intervention when patterns are identified.
3. Advanced familiarity with patient concerns and barriers to compliance and
the opportunities they present for corrective interventions, improvements
in systems problems and improvement in patient satisfaction.
4. Team connectedness and purpose around a common goal.
5. The impact of collaborative case management on patients’ appointment
and treatment compliance.
Amelia Williams has been the oncology social work coordinator at Grady Health
System, Atlanta Georgia for 4 years. A MSW graduate of the University of
Wisconsin School of Social Work, Madison, Wisconsin, she has 23 years of
experience as an oncology social worker and is a member of The Association of
Oncology Social Workers.