Data in Case Management

I am often asked what data should be tracked to show outcomes for case management and my response always starts with what outcomes do you want to prove? Data is a finicky animal; it can provide many results for many reasons depending on how it is used. Case Management in its broadest terms also can be defined in many ways depending on the setting and model and use. Whether we call it Care Management, Care Coordination, Case Management and include Social Work, Utilization Review and other parts that are usually placed within the scope of the work; data for outcomes can vary but at the core there are fundamental elements that I will endeavor to discuss and try to demonstrate how to track and display for a variety of stakeholders. I will not venture into all the definitions listed supra of case management in this article and use the broader term that encompasses the working case management model for purposes of data collection for discharge planning and utilization review. Those two terms then have myriad data points due to the nature of the impact to their respective role in their hospital or healthcare system which I will also limit within this article and not include our partners in insurance and the post-acute care world.

Data is now kept within most electronic healthcare systems in the United States, the vast majority of facilities have a rich and diverse repository of information that acquires data on each patient on a daily basis, whether directly in the electronic health record (EHR) or through a third-party system that is “attached” to the main EHR. Retrieving the necessary data can at times be an issue for case management due to a lack of direct access to the reporting tools or lack of knowledge of how data is stored within the EHR or third-party systems. Additionally knowing what data to retrieve can also be problematic if you do not know what outcomes you want on a month-to-month data or even in an ad-hoc basis. As with most outcomes you want to prove start with a hypothesis. What are you trying to prove, for most case management programs we are measured by our function of impact to the system by our executive team in terms of financial terms that determine net revenue or operating income or contribution margin. Knowing what your executive team expects case management to produce will allow you to concentrate on the data that should be gathered and tracked on an ongoing basis.

Per the latest American Case Management Association Survey of 2021 length of stay was the number one outcome being measured, at number 3 was observation rate within 48 hours followed by observation rate then observation encounters greater than two midnights. These are just but a few that should be tracked. At the end of the article is a typical scorecard that this author has used for many years to track outcomes. It includes an expansive area for length of stay that also has the case mix index (CMI). The Case Mix Index (CMI) is the average relative DRG weight of a hospital's inpatient discharges, calculated by summing the Medicare Severity-Diagnosis Related Group (MS-DRG) weight for each discharge and dividing the total by the number of discharges. Also, on the scorecard you should measure the CMI adjusted LOS which is a measure used by finance and is defined as a high-level measure of operational efficiency, eliminating higher or lower than average patient acuity. The scorecard has many data points and may not be needed for all circumstances as mentioned above. Track what is important to your team and executives. Additionally, you also need to determine the frequency of the data collection, this author produced the data monthly to coincide with the UR Committee meetings.

Displaying the data is another choice that needs to be made, Excel, Tableau, Charts, PPT and other methods can be made to display data. Choose one and be consistent in your approach, make sure it can be read easily, include where the data was retrieved from (source of truth) so that it can be duplicated by others, if need be, and that the data is solid. Ensure the data is correct, you may be challenged on the numbers so make sure you check for accuracy prior to publishing. If using a PowerPoint display, make sure it can be viewed easily (large enough font to read on a display screen whether in person or virtual) and include a guide for the reader for data you are presenting. If using charts and there are goals put in a line for the goals and mark it so that the target audience can see the goal easily and compare the outcome data to the goal line. Make the goal line a different color than the outcome data. When using Excel use red and green to show whether the goal was achieved or not for each month and include in the header what the goal is for each outcome measure.

One of the most important elements of data is to be precise when speaking about trends. This author learned early on when not to express that a trend occurs after 3 months when he inadvertently stated so in an executive meeting. He then was given a 3-hour lecture by the VP of Quality on how to measure data, how to use control charts and what is and is not a trend. We like to measure and celebrate success which is normal but to ensure accuracy in data we need to understand when data is really telling us that a true trend is occurring. Walter A Shewhart is considered the father of modern quality control and the lecture contained many elements on what Shewhart did to usher in the modern thinking on quality control. Per Shewhart 6 consecutive points that are steadily increasing or decreasing shows a trend up or down. He also stated that 8 of 9 points on the same side of the center line shows a small, sustained shift (a trend). You do not necessarily need to wait 6 months or 8 of 9 months for a trend, you can look at data over 6 weeks or 8 of 9 weeks to determine what direction you are moving. I would advise against doing this in days since that is too short a period unless you are doing a process improvement project in which you can use data in hours or days to try to determine if your process changes are working.

Lastly prior to putting in the examples of the scorecard data is only as good as the storyteller and the source of truth. By source of truth, I mean the main point of entry from which the data is retrieved. At times data is passed along several portals to get an output which at times can change the final outcome. You want reports that pull data at the point of entry. For instance, if you use an EMR that data is input for avoidable day entry then you want report to come from the EMR not a third-party reporting system. Same for LOS, you want the data from the EMR not a system that also tracks it since the data is not from the source of truth, original data. Data can be enlightening and can be used for many reasons including demonstrating how case management contributes to the bottom line of the organization, but it can also be used for process improvement and for personnel enhancement in key areas that might need more personnel or a shift in personnel. Remember we live in a data rich world but what we use is up to us.

Below is a typical scorecard with many reportable elements that was produced monthly. The scorecard was for a level 1 trauma academic medical center.