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Conduct a cost benefit analysis to improve care

Hospitals are under immense scrutiny to keep costs at an all-time low. Most case managers and social workers understand the various payment methods, especially case rate or DRG-based payments. Unfortunately, directors often don’t help their case management teams understand the difference between charges and costs; we also don’t explain how to use this information to change the situation on the floor.

A case management team that knows the costs of a room and basic services can determine whether a patient who doesn’t meet inpatient criteria should move to a more appropriate level of care for the duration of the hospital stay anticipated by the physician. This would improve care from both a medical necessity and economic perspective.

The following information is necessary to conduct a cost benefit analysis:

• The average cost of room and board at your facility
• The cost of any associated major treatments or equipment (e.g., ventilator)
• The number of days the patient is expected to stay in the hospital
• The cost of care at the proposed alternative level of care
• The number of days the organization plans to pay for care at the alternative level

First, multiply the room and board rate by the number of days the patient is expected to remain in the hospital. Be sure to include any associated major costs in the room and board rate.

Next, multiply the cost of care at the alternative level of care (e.g., SNF) and the number of days the organization plans to pay for care at that level

Finally compare the two amounts to determine which choice is more cost-effective.

Cost shouldn’t be the sole reason for placement at a lower level of care. List all non-financial reasons why the alternative setting will benefit the patient and hospital (e.g., avoiding hospital acquired conditions, family requests, etc.)

Transferring a patient from acute care to an onsite SNF or rehabilitation unit, when these options exist, may be appropriate and cost effective. If turf wars begin, a cost benefit analysis can resolve the conflict. It will demonstrate to the CFO that the cost of inpatient care is significantly higher than the cost of a lower level of care. This knowledge can promote proper intervention for the patient.

Other solutions exist for patients who are ready for discharge, but have nowhere to go. My facility had an Italian-speaking patient who was dying. We used a significant amount of resources to employ a telephonic interpretation service to communicate with him. The interpreter told us the patient simply wanted to die at home, in Italy.

Using a cost benefit analysis along with some creativity and influence, we were able to fly him home at minimal cost. The airline donated his ticket and a durable medical equipment company worked with us to minimize the cost of an oxygen tank. The airline returned the tank to the company on the return flight. We worked diligently with our risk management office to obtain all necessary signatures on various forms to eliminate any liability for the hospital and airline.

The patient’s family arranged for oxygen upon his arrival. The patient died four days later but he was able to spend his last few days with his family.

ER case managers must have special skills

A nurse case manager is a definite asset in the emergency room (ER).  An ER case manager benefits the patients, the staff, and the hospital.  The role is multi-faceted and requires superior skills in:

• Quality
• Education
• Communication
• Customer service
• Negotiation
• Creativity
• Risk management
• Knowledge and understanding of insurance requirements and regulatory mandates

It also requires an ability to interact with patients, families, insurance representatives, and caregivers both in the ER and those who are treating the patients in the out-patient arena.

Visits to the ER may have one of several outcomes. Usually, the patient is treated and discharged home with a plan or the patient is admitted to the hospital. It is here that the ER case manager can be most effective to improve the quality of care and prevent readmissions to the ER.

An ER case manager can ensure that each patient who is discharged from the ER has an appropriate discharge plan that is viable and appropriate to assist the patient in recovering and maintaining their health.  A case manager is an expert in confirming the patient can afford any prescriptions provided , is able to be compliant with recommended follow-up visits with  specialists and can assist the patient in connecting with a primary care physician. The nurse case manager can be instrumental in  working with the patient  and their support system to make sure that they understand and have the interest and ability to be compliant with the discharge instructions.

The case manager can enhance the care provided by a busy ER nurse and physician  by assessing situations and family dynamics, listening to the patient and helping them understand the rationale for various tests and the time needed to interpret results. The case manager can assist the ER nurse with patient education and  providing information necessary to maximize  the patient’s health status.

The case manager can also benefit the hospital by working with both ER physicians and admitting physicians to ensure that all acute care admissions meet medical necessity and are admitted to the appropriate level of care.  The case manager can assist with transfers to alternative levels of care such as skilled nursing or rehab when patients do not meet criteria for acute care but are unsafe to return home.  The case manager can arrange home healthcare, physical  and occupational therapy or other appropriate services to help a patient maintain their independence in the home.

Case managers are an integral part of the ER team to improve the quality of care and help maintain fiscal responsibility for resources both in the ER and on the hospital admitting units. Case managers coordinate care and provide patients will all the tools necessary to improve their quality of life and feel their best within any limits of their illness or disability.

What do hospital case managers do, anyway?

This is a question frequently asked by patients, family members, physicians, and other members of the medical staff.

Many people think that case managers are discharge planners, and that the only time a patient needs a case manager is when he or she has discharge needs. Case management is much more than that. It is important that we make sure that, not only do patients and families know what case management is, but that the nursing staff members know also.

Case managers work in forces behind the scenes, much like the crowd of people in the Verizon commercials. Case management is a hidden resource for patients. Often, the case managers work in the trenches, with their heads in charts, communicating with an interdisciplinary team of healthcare professionals to make sure that the patient is moving smoothly through the continuum of care, and there are no delays or detours in their care. This is usually an unknown aspect of case management.

Hospital personnel and the public need to be aware that case managers are advocates for all patients; they ensure that their healthcare facility and professionals are doing what is truly right for the patient, in the right setting, receiving the most appropriate care, and in the most cost-effective manner. Case management follows the patient’s plan of care to make sure that it is appropriate and timely, that their hospital admission status is appropriate, that their discharge planning is initiated, and that goals are set to meet the discharge plan. It is imperative that the case manager build a relationship with the patient and their families in order to reach a mutual goal of discharge.

It is also important for the bedside nurses to know that case managers are an excellent resource for them in planning the patients’ care and goals. One thing I did at our institution while we were redesigning our case management model was to do a mandatory in-service to nursing staff on how case management affects not only patient outcomes, but the financial outcomes for hospitals.

At our institution this year, we included a station on case management and interdisciplinary rounds at the nursing annual competency testing. Case management had a display booth with information about what case management is and the importance of interdisciplinary rounds. We also had a test for the nurses to complete. The comments we received from staff were very interesting.

Does your institution do anything like this? Are you confident that nursing staff members truly understand what case management is?

And one more important question: Do your physicians really know what case management is?