Case management tools can put the accelerator on progress in care coordination to improve quality and reduce costs. It can also drive a healthcare organization’s route to becoming an accountable care organization.
Case management can assure that provider teams collect and share the right information about patients to reduce readmissions and to receive the expected reimbursement from their payers, according to Tamara Pruett, director of case management at Banner Baywood and Banner Heart, part of the Banner Health network. A case manager can perform the review and screening work that is involved.
Banner Health, based in Phoenix, Ariz., is also one of 32 Pioneer ACOs named by the Centers for Medicare and Medicaid, she said.
“We know we have to change the practice of health care, and we know we have to focus on quality,” Pruett said. At the same time, providers have to achieve financial health in the current environment while “we plan for healthcare reform, value-based purchasing and then the transition to being a more accountable care organization,” she said at a recent care coordination conference sponsored by Dorland Health.
Built on electronic health records and other health IT, case management at Banner Health has advanced care coordination, including through:
1. Reducing readmissions. Banner developed a process in its workflow in which the staff can tag a patient who is at high risk for readmission using evidence-based criteria. The patient is stratified by the criteria to be low, moderate or high risk for any one of four conditions, such as readmission for heart failure. “Each time the patient comes in and the risk stratification changes, they can re-stratify the patient, and that remains on their work lists so they know who those patients are,” she said.
Banner also designed a standardized reassessment note with discrete data fields that can be reported on after it realized that historically patients haven’t been asked the right questions upon follow up. Among the facts Banner uncovered was that some patients were coming back for planned re-admissions, such as for chemotherapy treatment. With that knowledge, the provider can identify where the treatment might be delivered differently than as an inpatient.
2. Analyzing referral patterns. The system data shows where patients go and come from and how quickly and the time frame. The system provides the date that the patients who are readmitted were originally discharged and link that with their physicians and patient-level data. The availability of the information enables a unit with a high readmission rate to engage in an improvement process with its hospital-based physicians.
3. Collaborating on discharge planning. Banner is beginning to standardize across its facilities the practice of notifying primary care providers at the time that their patient is admitted and discharged from the hospital; communications are established with home care and other post-discharge services; and pharmacies are involved with call-backs to patients to make sure they pick up their medications and understand how to use them. Banner also partners with a Phoenix rapid care clinic to divert patients from unnecessarily using the hospital’s emergency department, which is across the street.
Banner centralizes discharge planning so that communications with home care and acute rehab is streamlined. The case manager puts in the request and works with the outpatient provider to make sure that the patient has that covered benefit. “We attribute part of our decrease in the length of stay in 2010 and 2011 to this process that we built,” she said, adding that the hospital has to have the data to assure that the patient received the appropriate care and match it to readmission data.
4. Assuring reimbursement. Banner centralized its payer requests for clinical reviews to accelerate the process to receive payment. A case manager can determine the review needed to be done, abstract the record and attach documentation to transmit to the payer. Banner performs about 3,000 payer reviews each month with an average time now of four hours. Previously, it was four days, Pruett said. Payment denials are rescinded 99 percent of the time now compared with 72 percent previously.
“By centralizing, it allowed us to see the volume of payer review requests and potential denials that were received every day. That was really important in being able to build partnerships with our payers as we move into the ACO time frame,” Pruett said. “The same case management and discharge planning system, which includes the centralized denial department, allows us to look at resource utilization, delays in care, process and physician opportunities, readmission rates, referral patterns and the denial data -- it all lives in one system."
5. Educating patients. Banner is phasing in patient education to meet the patient where they are and to make sure that they understand their health information. “If you give them a booklet, go through it with them, and [ask] did you understand it? We do follow-up phone calls,” she said. A navigator assists the patient in understanding health information and assuring that follow-up appointments are made.
“But using the technology to be able to say that these are the number of touches and tie that to the outcome is essential to being able to deliver highly coordinated care,” she said. “It definitely is supported by our C-suites and they see the value in it.”