And now I would like to reintroduce our speaker this morning to get us started with part five. Dr. Tony Sesta is a founding partner of Case Management Concepts, LLC, a consulting company that assists institutions in designing, implementing, and evaluating case management departments and models, educational programs, and on-site support for leadership and staff. Dr. Sesta has been active in the research and development of case management for over 25 years. Her research has included two funded studies measuring the effects of a case management model on congestive heart failure and fractured hip patient populations with measures of patient satisfaction, quality of life, and short and long-term clinical perceptions and outcomes. Good morning, Dr. Sesta. Thank you so much for being back here with us this morning to close out our series, and we'll go ahead and turn the program over to you. Good morning, Lindsay, and good morning, everybody. You know, Lindsay, I can't believe it's our last one. I think when we started, it was winter, and now it's spring. That's right. So how long have we been doing this? No, I'm kidding. Module five, you know, it's interesting because I certainly, when I was a case manager, would say, oh, outcomes, what is, you know, why do I need to worry about that, and what, you know, what does that have to do with me, and that's, you know, management's problem, leadership. But in today's universe where your outcomes are aligned with your compliance requirements and lots of other things, and because there are so many regulatory issues that bump up to us in case management that we've talked about over the many weeks, you know, it's important that you understand what these key performance indicators actually are and how you can impact them because that's part and parcel to why we have departments of case management. And so KPI, you know, key performance indicators, your organization may call them KPIs sometimes, some people call them outcomes. So, you know, when you just want to think pretty globally, well, what the heck are outcomes anyway, and, well, they're the right thing to do, they're the right idea about where to go. I like to think of them as goals or targets, and later on when we look at a case management report card sample, we'll see what I mean by that because we, and we could add objectives actually right there, so, you know, it's like what are we striving for? Why do we do all this work that we do? Why do we, you know, rush through our days trying to do a number of things for our patients? Well, it's because we want to hit these various outcomes. They're professional outcomes, as I said, they're patient outcomes, they're organizational outcomes. So those are our results, and then also standards. So the notion of outcomes fall into an array of different concepts, and we'll go through most of that this morning. So when you're starting, so many of you probably already have a report card of some sort or some measures. I'm sure if we asked the group today, pretty much everybody would say, yes, we are responsible for length of stay, and certainly length of stay was one of the earliest metrics that we began to be held accountable for, but I want to talk more about that in a bit. So you want to ask yourself a number of questions. How can I show that our program, our case management program is actually effective, is actually doing what it should be doing? How can we prove we bring value? The thing about case management is, and you know, I remember in the early days, well, you have to prove, when we would ask for additional staff positions, FTEs, we would always get asked, you know, what's the return on investment? I still hear that on occasion. We are not a return on investment department in the classic sense, because we don't bill for what we do, and we're just one of many team members that impacts on things like length of stay. So it's sometimes hard to prove our value. Where we are most effective is in cost avoidance, and that's the thing we never measure, cost avoidance. I'm going to give you one quick example, or I think it's two quick examples later on, of what cost avoidance actually means. And that's what we do when we shorten length of stay, when we reduce resources consumed by a patient, when we prevent a readmission, this is all cost avoidance, hard to measure. What benchmarks or industry standards are there for whatever metric you're selecting? If you don't have a benchmark or some kind of standard to measure against, it's not really a valuable metric. Where do we get good data? Lots of data. Is it the right data, and is it valid and reliable data? And then you want to ask yourself, are there any other broader ways or newer ways of looking at our department's performance? Is there something beyond the typical stuff for us maybe to think about? So improving your performance gets to what we're going to call the five no's. Know how you're performing and why, so how are you doing and why are you doing it? How your performance compares, so again, how do you compare to others? Know where you want to be, so those, again, you set your goals, your targets, and you want to use your best practice scenario in order to do that, which we will look at, know how to get there. So I don't want to pick some far-flung goal that I can never achieve. I want a goal that I know how to get to. And know if desired results are achieved, and that's really also where your scorecards or report cards come in because you need to have a way to monitor over time how you're doing, obviously. So value, I've talked about value in healthcare before, but I always think it's worth another look. So we can talk about outcomes, we can talk about key performance indicators, we can talk about cost avoidance and all of those things, but at the end of the day, we have a part to play in bringing value to our patients and to our health systems. So how do we get to that specific outcome without overspending? You know, it's really easy to get to some outcomes if you throw a lot of dollars behind something, but what we're talking about is having a balance between those elements. When we talk about value in healthcare, we want to talk about it around the patient. So the patient becomes the center, as opposed to the typical way we have looked at outcomes, and they weren't truly outcomes, but work around the patient, not look at volume. So for example, most executives, and I think I confessed that I have been one, you know, we look at things like, you know, how many discharges were there? Well, yes, we need to know that, but we want to know more than that. We want to know how many of those discharges we actually got paid for versus how many were denied. So just having a bunch of discharges without closing that revenue cycle loop isn't going to be particularly helpful. So measuring value in healthcare, you know, kind of takes that same analogy, you know, if you want to buy a car, if you want to buy a food product these days or anything, what you're looking for is value. You want to spend the least amount, but get the best quality item that you can. So in order to get to value in healthcare, we're looking at efficiency and care coordination as the two ways in which we can close that loop on how much money, how many dollars are being spent. So it's cost versus the outcomes achieved, you know, those are kind of juxtaposed, obviously, with each other. Now, we can look at it in terms of a patient's total cost for a full cycle of care. We're moving more and more in the direction of looking at a full cycle of care for a patient. What do we mean by that? Well, if you look at a bundled payment structure as one example where you're following the patient across multiple payers across that continuum that we had talked about, that cycle might be from the emergency department through rehab, for example, or cycles can be shorter. They can even be longer than that. And that's important in your accountable care organization structure as well. So the value equation is value equals outcomes divided by cost. And that's very simple, but a lot harder to do than it is to say or to just look at that. So you have to know first, of course, if you're getting value, what are those outcomes and how much did it cost me to get to that outcome? So you want to improve your outcomes. You want to be able to measure them and show them and show the value. Your senior leaders, you know, they can use your data. I have had many senior leaders use a high-level, use a case management report card as a high-level decision-making tool where they can look very quickly and see all the different outcomes, or they can drill down. Maybe they want to drill down to see, you know, what's going on deeper in the department depending on their interest. Financial data, you know, you can look at things daily. You can look at them weekly or monthly. Something like denials, as an example, should probably be looked at on a monthly basis because the changes would be so small if you looked more frequently than that. So when you're thinking about how frequently I want to look at something, you have to be very thoughtful in terms of, you know, how sensitive that measure is and how often it changes in a significant way. So the first measures, and I'll use the word measures or metrics, that we used in case management were productivity process and compliance metrics, and we still use these today. But as we go through these, you'll see they're not outcomes. They're not outcomes. How many of this did you do? Did you follow the right process? Were you compliant? Those are important things for us to know, but they're not outcomes. So, you know, if your boss wants to measure how many insurance reviews you completed for the month, you know, okay. Were your admission assessments completed within 24 hours of admission? So anything of this nature, it's important to track and trend. It helps understand the volume of the work that you all are doing and whether you're following, as I said, following processes, many of which are mandated by Medicare CMS. So the choice list, the two midnight rule, you know, code 44, the moon, all the things we've listed here really are important to take a look at, but they're not outcomes. So what are outcomes for us then? Well, I've put them into three categories, financial outcomes, clinical outcomes, and service outcomes. And you've certainly probably heard about the financial and the clinical, but I've added service. So, again, questions, what are the objectives of my department? Do you, if you're our inner social work case manager, as we speak together today, do you know what your department's goals are or objectives are? You know what you're being held to account for? Is it that length of stay or is it something else or more than that? So what is the department trying to achieve? Has that been clearly articulated to you and do you understand it? And then more broadly, what impact are you having on the organization at large? And finally, and particularly for our leaders listening today, you really do want to think about when you do talk, either talk about an outcome, present some kind of a chart or graph with outcomes or that report card, you want to make sure the way in which you're presenting the outcome is understandable to other departments and disciplines. There's nothing worse than using a lot of jargon that's very specific to case management that others aren't really going to understand. It really takes the wind out of your sails. You may have an amazing outcome or sets of outcomes and then you start really kind of washing over it with a lot of jargon and abbreviations and you shoot yourself in the foot. So just be thoughtful about that too. You don't want to be redundant. The thing about some of these metrics is we're not the only department tracking them. So finance looks at length of stay, for example. We look at length of stay. There's probably other departments in your hospital that look at length of stay. So while we try not to be too redundant, it's just unfortunately going to happen. What data are other people collecting? So if finance, for example, is collecting length of stay data, you want to know are they using that geometric mean length of stay, are they using the arithmetic mean length of stay, because those two differences can make a difference in terms of whether or not your data looks very different from theirs. That's not a good thing, right? So if you're reporting length of stay or setting targets for length of stay in your department and you're way off from how finance is doing it, well, that's going to look bad later on when there's some comparisons discussed. So you want to make sure you're in sync, as an example. Who sees the data? You're going to have to think about what format you want to put data in, depending on who the audience is going to be. The other question always is, are my goals, are my department's goals aligned with the hospital's strategic goals? You have to ask every year, because usually the senior executives have some target performance they're focused on for a particular year. So this year it might be reducing heart failure readmissions, or it might be reducing the cost of hips and knees. There's a variety of projects. They could be three-year plans or one-year plans, but you want to make sure whatever you are also highlighting is consistent with what they are highlighting. Again, are they clearly defined? So behind every goal that you pick, you want to make sure it's definable, and it is defined, and it's also measurable. So it's hard. A couple of the outcomes I'm going to show you are not clearly measurable, and yet I've included them. Well, why have I done that? Well, you'll see why as we get along to that, but typically in the aggregate, if you can't measure it, it's not a valuable outcome, and then you should go over them annually. When you have an outcome that you've been perfect on for quite a while, and by quite a while, I'm going to say like three years, you can probably eliminate that one from your report card and maybe add something else that you may be not doing as well on. I know that sounds weird, but just to keep reporting something because it's good probably isn't a good idea. I would circle back to it maybe a year or two later and check and see if there's been any slippage, but you don't want people to numb out when they look at this stuff. So just to recap then, you want to have clear and precise definitions, and what I tell my clients is make sure for every metric, not only do you have a definition, but what I help my clients do is create a definition sheet, and that's sort of, I don't want to say it's hatched, but it's part of the Excel spreadsheet so that each and every one of those metrics has an understandable definition behind it that anybody could read. Is this outcome under the department's control? Well, I'm going to tell you, most of what we measure is only partially under our control, like we said about length of stay. We're not the only ones that impact on length of stay, and yet we so often are held to account as the sole owners of length of stay, but my goodness, every other pretty much department and discipline in the hospital has some measure of accountability for length of stay. I think back in the day, there was this false notion that managing length of stay was all about discharging, and if we could just discharge everybody fast, we would manage our length of stay. Well, today we understand the process, the throughput process of our patients to be much more complicated than that, and therefore, we have to think about anything and everything that happens as that patient transitions through the acute care continuum. Remember when we talked about avoidable delays, and we're going to talk about them again today, well, those are the ways you start to chip away at some of the other barriers to that patient moving smoothly through the hospital stay. Now, risk adjustment, I don't want to bog you down with risk adjustment, but what risk adjustment is about it? Let's say you're specifically looking at good old heart failure. You're going to have heart failure patients that are, you know, level one, low grade, if you will, all the way up to people who are intubated and everything in between. So sometimes when you're looking at something with a lot of variation like that, because your resources you would apply to the very sick heart failure patient obviously are much more costly than the resources you would apply to a low-level heart failure patient, well, you don't want to measure them against each other. It's not really fair. So this is where this risk adjustment comes from. It's mathematical. It's not something you all need to know. It would be done by a data analyst if and when you needed to do that. But I just wanted to mention it. Again, are the metrics meaningful and measurable? So as I studied outcomes over the years, you know, and I thought to myself and I talked to others about the fact that, you know, we might own length of stay, but we are not the only ones impacting on it clearly. I decided to put the outcomes into these levels, if you will. So I defined some outcomes as organizational, and that means they're affected by multiple departments or disciplines. So again, length of stay affected by, oh, my God, who are they not, who is it not affected by? So it could be radiology, pharmacy, laboratory, case management, nursing, the doctor and on and on and on. So yeah, we might report on it, but we're not the only ones affecting it. And somehow you have to get that across, you know. I mean, I think people are getting to understand that, but you don't see other departments reporting on length of stay, so somehow it kind of stays with us. And then we have departmental outcomes, those are affected by the department specifically and only. And then staff. Now, these, again, not necessarily outcomes could be, but more of those process measures that we looked at at the start. So let's start then with some of our financial metrics, which are all organizational. And by that, again, I mean that if you look at all of these financial metrics here, they're all affected by multiple departments and disciplines. So denials are another category that we typically are the ones reporting on. And so somehow we own all denials, but we all know that there's so much more that goes into controlling your denial rate. So the key performance indicators then for financial are your overall denial rate, your clinical and technical denial rates. Now you may call technical denials, you may call them administrative denials. I'll explain the difference in a moment. Appeals, overturned rate, your length of stay, again, and average cost per day or average cost per case. And then as we said, you have to have benchmarks. How do you know whether you're doing better or worse on a key performance indicator if you don't have some kind of a benchmark? So overall, and I prefer, I always prefer to report denials as a percent of patient days because then you can say of all these days we treated patients, this is the amount of days we did not get paid for. So you can certainly not do it that way. You can say we had 200 denied days of X number of total days. I mean, that's the same thing. But percents kind of get people's attention. But, of course, that's certainly up to you. Your clinical rate and clinical denials are things like admission denials, continued stay denials, whereas technical or administrative denials are we fell outside the contract. So maybe a request was made for a medical record and we didn't get it to them on time. Maybe we got our clinical review in past the deadline as per the contract. Those are technical, meaning it's not related to the patient. It's related to our compliance with our own contract. And so, as I've said many times, we have to be able to see the utilization management portion of the contract or we're not going to understand exactly what those rules of the road are. So we have to be able to see these things and what we're being held to account on. Appeal overturned rate. You know, it hovers around 50 percent, and there are going to be denials that you're not going to appeal. But on those that you do appeal, you should win them at least half the time. So for length of stay, your benchmarks can come from the efficiency measure. They can come case-type specific. They can come from the CMS chart. If any of you were in the basic boot camp, Module 1, you looked at the chart of some of the DRGs with the expected length of stay. You can work off something like that. And or your finance department may have a target. So you want to collaborate with your finance department when you look at these things too. Now, again, with your average cost per day or case, you're also going to use the efficiency measure, which will give you cost measures. And hospital-specific rates based on these direct costs. So these are resources directly applied to an individual patient. And if you're looking at a specific disease group, that really is the way to go. So good old third-party denials. And again, you know, this is something we own. So on the left, I have those affected organizationally. And on the right, those affected specifically within the department. So you want to look at changes in volume of your initial denials received. Are we getting less initial denials? So an initial denial comes in and it's before we have appealed it or done anything with it. You want to measure changes in volume of final denials after appeal. Again, how many did we win? How many did we lose? And on the losses, were there any patterns? Measure as a percent of patient days, as I said just before. Your denial reversal rate. And your aggregate by physician and payer. Now, if you're using a good software, case management software program that allows you to put in not just the physician of record, but the reason for the denial and the number of days and all that, and the payer, you can certainly run a report on a specific physician or a specific payer. The payer data can be really helpful for whomever is the one negotiating your managed care contract. So they can see that one payer maybe is arbitrarily, you know, denying at a higher rate than another. And on the departmental side, this is to measure the impact of your physician advisor on denial rates. And you're going to have two places in which your physician advisor may intervene. One is on a concurrent denial, and a concurrent denial means it's a denial that happens while the patient is still in the hospital. And that's a great place for your physician advisor to enter the process and appeal. And then measure impact of physician advisor on length of stay. So if you keep track, and we're going to look at a way to do that shortly, but if you keep track of how many cases, in which cases your physician advisor touched, and again, you can often do that in case management software, you can look at how many cases he or she touched and what that impact was. So if they shortened the length of stay by facilitating an earlier discharge, well, you want to get credit. Again, that's that cost avoidance that comes in. That's sometimes really hard to measure, but these are examples of how you can actually do that. So measuring your physician advisor's effectiveness requires that you have a clear and he or she have a clear understanding of what it is that they're doing. So they're going to support your clinical review function regarding medical necessity. So by that, I mean, you know, when you have those questions and you want to run it up the flagpole, you're often going to speak to your physician advisor. They act as a liaison between the managed care company, the government auditing bodies, and the hospital to assure optimal payment when appropriate. So what does that all mean? That means if I'm getting a concurrent denial, for example, I'm going to ask my physician advisor to negotiate and speak to that managed care company. They may be one of the leads if you have a joint commission come in or if CMS comes in and wants to look at your short stays or whatever it might be. They should review all potential and actual denials that are referred by the case managers for medical necessity. So those are either concurrent or retrospective. They can be medical necessity on admission or continued stay, and, you know, if you get them involved, it helps you ensure that you're making the best decisions and you really have to have a physician involved anyway. So they would use the concurrent appeal process for concurrent cases when they feel that those are medically justified. And the reason I added, despite lacking adherence to standardized criteria, you know, Milman or InterQOL, is because CMS and, you know, nobody ever says you must exactly meet whatever guideline you're using. It's supposed to finally be up to the physician's discretion. So if the attending physician and the physician advisor both believe that despite the fact that the patient didn't meet criteria, it still is clinically appropriate, then, you know, then that's the decision that will be made, and hopefully, you know, it works out. They can also help write appeal letters for those retrospective denials that you felt were medically justified, again, despite the lack of adherence to your standardized criteria. Okay. I don't know. I hope you guys can see this, or maybe you'll print it out later. This is just a very small example of a physician advisor tracking sheet. So I always broke mine out by department. So up on the left side, you see medicine, neurology, and then I have columns for concurrent denials, retrospective denials, and non-denials. What do I mean by that? Well, that's where a denial was prevented. Again, cost avoidance that you can actually keep track of. And then non-denial outcomes on the bottom. So cases, outcomes, and then non-denial outcomes. So cases, outcomes, it could be other things. So in other words, other things that your PA gets involved with that aren't necessarily related to denials. So if, again, they facilitate an earlier discharge or further a discussion between a managed care organization and attending, you know, they might, again, the outcome might be a length of stay reduction, for example, or the prevention of a denial. So you just, you know, you can twist and turn this, any which way you please, depending on exactly how you want to focus. But at the end of the day, it's the PA who takes responsibility for filling this in. That's why if you have it in a database like case management software, then, you know, the PA, as part of their daily work, as part of their daily documentation, they can just fill in this data and then total it at the end of the month. And it just makes it very simple. So we looked at some of the classics. We looked at length of stay and denials in particular as being sort of your classic length of financial metrics. So let's look at some other KPIs that are also under the financial category. And I'm just going to take a sip of water here. Okay. So on the left, again, these are data sets that we should keep track of. I'm hesitating because this is really for our leaders today. But you guys, if you're case managers or social workers working with patients, you need to understand what is being looked at because you do impact on it. So short stay, that's three times fast. So short stay patients, those that stayed less than two midnights as, you know, an inpatient. You want to look at them by type, diagnosis, level of care, appropriateness. Part B write-offs. Physician advisor, again, the number of accounts. Physician advisor referrals and dollars. Observation length of stay, too. We've mainly been talking about inpatient length of stay. But remember, the payment you get for observation is predicated on a 24-hour stay. So keeping track of that is really important, particularly if you start to have some patients who are, you know, lagging and staying in observation for a longer period of time. In the ED, increased level of care. So reviewing the case, the physician doesn't want to admit, but you believe the patient meets criteria for admission. Or decreasing, much more common probably. Patient is admitted or they're considering admission and you don't believe that patient will meet that level of care. Then your use of Code 44. Dollars lost because we didn't bill as an inpatient. Or Code W-2, which is that Part B billing. Dollars lost on that. So these are really sophisticated financial metrics. But, you know, once it's set up, it's something that, again, can be done fairly easily. And then as we've talked about avoidable days slash delays, let's just look at how this data kind of relates to your length of stay. And in addition, this is a way of reporting your avoidable days that is very compelling to people. So track daily. You want to break it into your categories, right? So if you remember, we had a hospital system, systems outside the hospital. We had payer. We had patient, family, and so forth. So you're going to track your data every day. And now here's where it gets interesting. You want to look at your total avoidable days against total number of excess days. So what does that mean? So excess days are the numbers of days beyond the expected length of stay. So as I said earlier, you want to have an expected length of stay that's either ALOS or GMLOS. Once you've exceeded that expected length of stay, then those are excess days. Not all excess days are avoidable. So if the patient was really sick and they were intubated and what have you, they probably exceeded the expected length of stay, adding a lot of excess days that were not avoidable. So you can't say every excess day is avoidable, but you do want to report the difference between your excess days and avoidable days. And then identify the reasons for the excess days that were not avoidable as well as those that were avoidable. So you're going to have avoidable delays and then you're going to have excess days that were clinically appropriate. And when you pull out the clinically appropriate excess days from the avoidable, it's amazing how often those longer stay patients, the ones that exceeded the expected length of stay, were very much appropriate. And it wasn't about discharge planning at all. Okay. So those are a lot of different financial metric examples. Let's take a look at the key performance indicators that I've put on the clinical side. But you can argue with me that maybe readmission rates should be on the financial side since there is a financial penalty now for readmissions. And that's fine. It's really up to you which bucket you want to put them in. But it's very easy to pull up your readmission rates, 30-day readmission rates from Hospital Compare. Discharge delays. I put length of stay greater than 7 days. Your department may use 10 days, 5 days. I've seen it all. Depends on how you want to do that. Turnaround time delays. So that really gets to be very specific. What's your hospital's turnaround time for an MRI? And that means from the time the physician orders it to the time it's completed to the time that you get the results back. So you may have an 8-hour turnaround time for an MRI in the hospital. You may have a 24-hour or 12-hour turnaround time for a CAT scan. And usually, you know, and not usually, your radiology department should know what those are. So it's a simple question to ask. And so you know as a case manager if your patient's been waiting for a day and a half for an MRI, well, that's a lot of extra time that has to be accounted for. And it affects the patient clinically. From a quality-of-care perspective, because their care can't be progressed or diagnosis made until that test is completed. And then the efficiency measure, which we'll talk about more today, again, looking at length of stay and cost. You know, we typically focus on those unnecessary readmissions, but you also have to think about inappropriate or unnecessary admissions. Now, we often think of them as, quote, social admissions, but it's not necessarily just a social admission. It could be a patient who got admitted, who shouldn't have been, who fell through the cracks. And unnecessary resource consumption affects quality for other patients. Patient flow, the more patients in the queue, the longer the wait times. Length of stay for the same reason. Patient safety, bed delays. And if you're not getting a denial now from an unnecessary or inappropriate admission, you may get one later, whether it's the RAC, the MAC, the prepayment reviews, you know, we could go on and on. If you're in a bundled payment methodology, oh, yes, you do not want unnecessary admissions or readmissions, for that matter. And all of this is going to affect your efficiency measure in a negative way as well. You also probably want to look at discharge delays since that's something, you know, that falls. Yes, it falls organizationally, but we're the drivers of that process for sure. Maybe there was a delay in discharge because of a lack of, let's say, bed availability in the community. And conversely, it was your physician, internal physician, who delayed the discharge. And that's another one, you know, you want to bring that to your PA. Readmissions, because CMS is measuring them in 30 days, as we know, you probably want to start there. But, you know, if you're able to pull this data out pretty easily, you might want to look at same-day readmissions next day or 15-day readmissions. They tell you very different things. If somebody gets readmitted 29 days out after discharge, you know, that's a very different scenario than somebody who comes back the next day or even the same day. Something terribly, terribly failed for somebody to come back the next day or within 15 days. But we still have to look at our 30 days because we're being measured on that. So, again, those delays in care delivery that we were just talking about, turnaround times, tax, as we call them, test, treatments, procedures, consults, anything else that falls in that category, delays in care delivery, and then delays in getting the test results, that is a problem that used to be big. That is not so much anymore. And that's mainly, I think, because we have so much more electronic capability as far as getting test results that it's really not the big deal that it had been. But, you know, keep track of it anyway. So let's just talk for a couple of minutes about the Hospital Readmissions Reduction Program, always a mouthful, HRRP. I don't think many of us use that particular acronym. So the Readmission Reduction Program started up under the Affordable Care Act. You know, there was a lot of discussion. Some of you may recall a lot of heated arguments between physicians in particular and CMS about what was going to be included in this program. The physicians wanted to exclude unrelated readmissions or planned readmissions, and they did not win that argument. So you could have somebody be discharged after a fractured hip, come back with an MRI. That counts as a readmission. And if it's a planned readmission, it counts. So not fair, maybe, but that's the way they did it. What they said was, well, you know, the likelihood of that happening is so small. And, you know, CMS always speaks in the third party, so third voice or however you say that. So they said, we believe that in the aggregate this is very unlikely to occur. And they meant, you know, that somebody leaves with one thing and comes back with something completely different. I'm not so sure about that, but that's what they said. Now, they did exclude some things from the readmission roles. In-hospital deaths. Okay, great. Patients not enrolled in the Medicare fee-for-service program for at least 30 days after discharge. Very unlikely to happen. Patients discharged against medical advice. So if you've got a patient who leaves against medical advice and then gets readmitted, you will not be penalized for that. Patients under 65, and that just simply means this is a Medicare program, transfers to another acute care hospital don't count, and same-day discharges don't count, but only for AMIs. This is an interesting little graph here of hospitals that have been penalized for readmissions because I've certainly heard this from administrators. Oh, it's such a small amount of money. You know, let's take our chances. We'd rather get the readmission than not get the admissions, the flash readmissions. So, you know, we'll take our chances. However, you know, there's been a lot of hospitals that have faced penalties. Almost every hospital has faced penalties. And so, I'm just looking down here at Georgia because a lot of you are from Georgia. And let's see. What color would you put? That's more... So, if you look at the little color graph there, the little side, zero is the very, very pale, and then 100% Georgia, you know, not the worst, but leaning more toward the darker side. So, you can look up your current denial rate on the CMS. Excuse me, readmission rate on the CMS website. So, the other thing people questioned or complained about was how to risk adjust for these readmissions. So, they do allow and adjust. Again, this is done as a mathematical thing. They are adjusting for case-mix differences based on the clinical status of the patient. So, demographic variables, comorbid diseases, and indicators of patient frailty are adjusted. They don't adjust for complications, admission source, socioeconomic status, hospital size, specialty, or location. Now, this was also a bone of contention, but look over to the right. Safety Net Hospitals now have their own comparison group. I have worked in an inner-city Safety Net Hospital. So, Safety Net Hospitals typically get a little bit more money because they take care of a higher percentage of the Medicaid population, and what they complained about was that they also have a higher than, quote, normal readmission rate. So, after a time, they got pulled out and they have their own readmission comparison group now, and I think that was a really smart move by CMS. So, if you work in a Safety Net Hospital, you have your own comparison group. It's not really fair to compare you to some of the other hospitals. Well, what's included hasn't changed in nine years. So, easy for you to remember, and we started off back in 13. I can't believe it. AMI, heart failure, and pneumonia, as you will remember were the first three. And, oh, my God, everybody just got crazy, you know, trying to figure this all out. And what I kept saying was, if we have a program that addresses all the different causes of readmissions, it doesn't really matter what diagnosis it is. I mean, there are additional things you might do for heart failure, for example. But many of the things you and I have talked about over these weeks would impact generically on readmissions. And so, whether it's looking at the root cause when you do your admission assessment and then addressing that in your discharge plan, that's one way, lots of other ways as well, to impact on your readmission rate. And it's part of our responsibility as case managers. So, today, as of fiscal year 24, you see what we've got here now. So, who knows? I thought they were just going to keep adding, frankly. I predicted they were going to keep adding diagnoses until there was nothing else to add and they were just going to put the penalty on everything. That they have not done, interestingly enough. They've stalled with these that you see here for the last nine years. Good or bad, I guess it's good. So, if you do worse than the national average on any or all of these, then there is a 3% penalty applied to all your Medicare discharges for that year. Some folks think that you only get a penalty for that actual patient who was readmitted. No, it's all of your Medicare discharges for that year. So, that's why it can add up to a lot of money. And it doesn't have to be all of them. If you did poorly in any one of those, meaning worse than the national average, and that's why virtually every hospital gets some kind of a penalty. Okay. Now, these are not real numbers, so don't freak out. These are sample numbers. They're not real. But I just wanted to show you that, you know, you have your diagnosis, you have your national ranking. So, it'll say, then, say no different than national rate, better than or worse than, and then they'll give you the actual percent that you're working towards. So, you can build this into any kind of a report card for readmissions that you might want to develop. As far as the value-based purchasing domains and measures, these also, in terms of percentages, haven't changed in a super long time. So, we have the four categories that we've had for a long time, clinical care and outcomes, person and community engagement, that's your HCAHPS, the efficiency and cost reduction measure, and I have said many times, and I'll repeat myself, that's the one that I think we can have the biggest impact on as case managers, safety and then dollars at risk, 2%. So, it's interesting that they've leveled out at this 25, 25, 25, 25 now for quite a number of years. So, I think it's important that we, you know, really think about how we can impact on that efficiency measure. That's the one. Okay. So, the efficiency measure, which is called the Medicare Spending Per Beneficiary. I always say it wrong, but that's what it is. It's the efficiency measure, and the efficiency measure was really aimed at getting hospitals more accountable for cost and length of stay. We really hadn't had a measure that looked at those before this efficiency measure, but, again, they kept it somewhat limited. So, it measures for heart attack, heart failure, pneumonia, and hip and knee replacements, and they're looking at your payments associated with a 30-day episode for the heart attack, heart failure, and pneumonia, and for the hips and knees, a 90-day episode of care. And those are the only ones that fall under the efficiency measure. Now, that's not to say we shouldn't be efficient with all of our patients, because we should. So, it looks at your Part A and your Part B so that your inpatient and outpatient beneficiary spending during what they're calling a spending per beneficiary episode, and we'll look at what that means. So, it spans from three days prior to the hospital stay through 30 days after discharge or 90 days if it's hips and knees. Transfers, readmissions, and additional admissions are included in the 30-day episode. So, patient gets readmitted during that time, transfers during that time, or has other admissions during that time. It all counts in terms of the cost. The result you get is a ratio, and the ratio is calculated by dividing the amount Medicare spends per patient for that episode of care at the hospital by the median or middle amount Medicare spends nationally. So, it's comparing you against all other Medicare patients in the country, and it is adjusted for age and severity of illness. So, the episode begins with the admission itself, but, again, they're going to go back, so hang on. For the heart attack, heart failure, and pneumonia measures, payments across multiple care settings include services and supplies. So, it could be inpatient, outpatient, skilled nursing, home health, hospice, physician and clinical laboratory, ambulance services, DME, prosthetics, orthotics, and supplies, and those are all put into the measure for 30 days. For hips and knees, it's those 30 days and then continues on through 90 days. So, obviously, what they're doing is they're incentivizing us to be more cost-efficient. So, they're looking for a lower number here rather than a higher number. So, it kind of looks like this. I guess a picture is worth a thousand words. So, let's say we have our hospital admission there in the center, so we go back three days prior to admission, and then for those diagnoses we just talked about, 30 days after discharge, and, again, includes transfers, readmissions, and all the others, and includes Part A and Part B spending. So, they started off originally with expected score of 1.0, and then as hospitals started to do better, they naturally reduced it to .98, which is adjusted for case mix and geographic differences. Lower is better. So, again, if you are at a .85 and the expected score is .98, that means you're 13% less than expected, which is what you want to be, better than expected. Higher is worse, so if you're 1.1, which is 12% higher than .98, then you're doing worse than expected. And you can, again, check your own scores on the CMS website. So, as you get the scores and they say you're equal to the national average, that means that Medicare spends about the same per patient for an episode of care at your hospital as it does for the average hospital nationally. So, these are really cool benchmarks because they're national benchmarks. A ratio that is more, that means that your hospital is spending more, and obviously a ratio less means you're spending less. Again, these are not real numbers, but you can look at things like the overall rate, hospital rate, they'll give you your hospital rate, and your state rate, and the national rate. So, I just put the hospital rate at .96, the state rate at .98, and the national rate at .98. So, this hospital is doing better than their state average, better than the national average. And then you can get payments. So, you can look at your payments for heart attack, heart failure, hips and knees, and pneumonia, and they'll tell you you're no different than the national rate, and here's the national rate. You're less than, and here's the rate. So, if you see hips and knees here greater than national rate, that might be a good way to focus on hips and knees. Maybe you have a little bit longer length of stay than you should. Maybe you have other issues associated with this patient population. It gives you a jumping-off point to take a look because it's not going to be just one thing. Once you dig into some of this stuff, you uncover, you know, bunches of different things. So, again, I think there's just so many ways in which we can impact on our spending per beneficiary score, and it is a great performance-improvement project, and it's one that you can get other departments excited about, too. So, you want to manage the resources during the stay. You want to stay within whatever guidelines you use for pneumonia or heart failure. Focus on successful and efficient care transitions, which we've talked about. You want to make sure that transition is safe, and timely, and well-planned so that patient doesn't come back. Hardware your multidisciplinary teams, whether that's for walking rounds or just for care management purposes. You just really do want to make sure you know, everybody knows who the team is. Manage your discharge plans very carefully and actively from the day of admission. Manage keeping the patient out once discharged, so that gets to your ED case management program and how you're going to address those patients when they arrive in the emergency department. And then, as we've talked about, align with those next level of care providers. So, these are strategies we've talked about for lots of different purposes. We talked about how to do it on walking rounds, and look at how it's going to not just impact on length of stay, but it'll also impact on cost and readmissions and so many other things that, you know, it's hard to say, no, we don't want to do that because it has such a broad impact on so many things. Excuse me. I had also mentioned earlier about service metrics. These are kind of, you know, if you... Well, obviously, the patient experience is a KPI that's most important here. So, your HCAHPS scores, and we'll look at a couple of sample questions in a moment. But other things I have done, particularly once we've kind of started, let's say you redesigned your case management model, for example, or you did something dramatically different in the department, or you just want to kind of see where you can improve. You know, you can have a physician satisfaction kind of town hall meeting or use a survey. There are surveys, you know, for this. And staff satisfaction, same thing. You know, get impressions from other staff, from staff nurses and others, in terms of, you know, how can we work better together? What can we do differently? So, in the beginning, I said it's harder to measure. A couple of the ones I'm going to talk about today, and those are two of the ones that are a little bit harder to measure. It's a little more anecdotal than it is hard data, but it's worth it. I've done it, and you do get some interesting feedback that can be helpful. So, there's a lot of patient experience questions. I think these two relate to our work. So, patients who reported that, yes, they were given information about what to do during their recovery at home, or patients who strongly agree they understood their care when they left the hospital. So, we have an impact on both of those, obviously. And the thing that, remember, I guess it was last week we talked about health literacy, and we talked about the fact that so many patients don't necessarily understand what it is we're saying to them, or they can't act on the information that we've given them. And so, they would score lower on health literacy. So, when you're giving patients information about what to do during their recovery at home, you want to do it slowly, carefully, thoughtfully, and repetitively. You want to say it over and over again because patients are not going to take it in, absorb it, and act on it in the majority on the first go. So, you don't want it to be an afterthought as they're wheeling out of the hospital, but rather a daily, repetitive discussion with them about what they're going to do when they go home. And then giving them information is one part, but did they understand it? So, in order to impact positively on both of those things and have a better score, you definitely need to be as repetitive as possible. Okay. So, let's take a look at measuring your outcomes against national standards. Benchmarks are really important, and without benchmarks, it's hard to be clear on some of these measures. So, we looked at this. Again, you want to look at your overall denial rate, less than or equal to 4% of patient days, clinical, less than 5% of patient days, and technical, less than 3%. And your overturned appeal rate, again, I'm telling you around 50% is good, good, good. Length of stay. You can use your efficiency measure. You can break out your length of stay by payer. So, you might want to look at Medicare separately for Medicaid, separately for managed care, because you're going to see typically a lower length of stay, shorter length of stay for managed care, and the longest length of stay for Medicare, and Medicaid typically somewhere in between. So, sure, you have to look probably at an overall rate, but you can also break these down. It's not that hard to do. You can look at it regionally, your region, or obviously case-type specific. If I'm going to do that project, I'm reducing cost for my hips and knees, well, you know, obviously length of stay is part of that. Average cost per day or case, again, through the efficiency measure, if it's a diagnosis that applies. You can compare to national rates, or you can look at your own hospital-specific rates. And, again, these are your direct costs to take care of a patient, lab, radiology, pharmacy, and so forth. If you have a cost accounting system, as we've discussed, that's clearly the best way to be able to do this. Doing it any other way is a lot more or a lot less accurate. And then your short-stay patients. CMS wants to see this as an exception, not the rule, patients who are inpatients for less than two midnights. So this is something you kind of want to keep your eye on. Do you see a pattern in types of patients, appropriate level of care? Maybe they were appropriate for short-stay inpatient experience. Or how many of those were actually then converted to inpatient? Important to keep an eye on. Okay, for the clinical benchmarks, we talked about the readmission rate, the discharge delays, your turnaround times, and your efficiency measure. Okay. Okay, I got copied here. All right. So in the beginning, we looked at some of the key performance indicators for staff performance. I get asked this question a lot, you know, like, how do I measure what my staff are doing? How do I know if they're doing a good job and stuff like that? So these are the productivity indicators. Now, you can measure how many reviews you guys did, but, you know, one review is going to take longer than another, so you have to come up with some kind of an average. If you are a case manager who's only doing clinical reviews and not doing discharge planning, then the benchmark is 30 per day. Is your admission assessment completed on the day of admission? Are you following your root cause analysis process? So I should be doing that on admission and incorporating the corrective action for the root cause that caused the readmission into my discharge plan. Number of referrals to nursing homes or to subacute. You want to come up with some targets. In talking to home care, which is the bottom line there, they gave me an 18% for a referral to home health, so you can do that, you can use that, you can set up your own based on prior performance, perhaps. And then for those process and compliance indicators, your KPIs include the choice list, the two-midnight rule, Code 44 and 121, the moon, the second important message, all the things that we have talked about, because these are compliance issues as well as process. So you need to know the process for when you need to do a Code 44, for example. You need to know the process for all of these. Now, measuring these leaders is sometimes going to require direct observation, or sometimes it's going to require a chart review, just really hard to get away from that sometimes. Just a couple of examples here of how you can track cost avoidance. We talked about it in terms of your physician advisor's work, how you can use your PA to help track cost avoidance when they get involved. A couple of other examples that would... The first one would be from the ED, and again, these are not real numbers. So you might have two social admissions, quote-unquote, from the ED per month that you've avoided. At an average direct cost, let's say your hospital gets paid $1,000 a day and the length of stay of two days. So over the course of a year, you saved $48,000, and those are very low numbers. Two patients per month with expedited discharges. So sometimes, you know, we've all done it, the patient needs a plane ticket, a train ticket, medications, home health, or some other service that is not covered, or they're uninsured or underinsured, or whatever it might be. So if you pay for that, you expend that amount of money, and then you separate that from the amount of money that you saved by facilitating the discharge, you can keep track of that. I would definitely suggest that you put that on your report card because nobody's going to understand that you did that unless you report on it. Now, some of you may be responsible for case-mix index in your departments. If you remember way back, we talked about case-mix index, and it's just the average of all the weights, the relative weights for all your DRGs for discharges for a period of time. Now, if you have clinical documentation improvement under your department, then you definitely are going to want to track case-mix index. You can see when you reduce inappropriate admissions that are less complicated or don't have comorbidities or are really just symptoms, you're going to have a positive impact on the case-mix. So in that regard, we do impact on case-mix. But it's also a good barometer of how well the hospital's doing financially. And getting rid of those one-day stays will also mean a higher case-mix index. So there are many ways in which we also impact on that. Now, it is a very sensitive, very sensitive number, meaning by that I mean simply that a small change can result in a lot of money. So it is worthwhile to keep an eye on. So in this case, these are just, again, made-up numbers. So this hospital had a case-mix index in 2021 of 1.567. And then in 2022, it dropped to 1.467, which was a reduction of .1, .1. .1. Now, if they were getting paid $4,500 per discharge and they had a .1 reduction, that was $450 per discharge times 5,000 discharge. Just that .1 and very low numbers here, they lost over $2 million. So a .1 change in case-mix index, that's what I mean by a very sensitive number. Small change, big impact. All right. How about now we look at the report card? If you have a report card now, just follow along with me and see if you're going to hit on most of the things I'm talking about today. If you don't have a report card, what I'm walking you through is a way to set one up. So first of all, you need to know what you want to measure. What are the outcomes that you want to keep track of? Once you've picked those out, and you might want to start smaller at the beginning. So in the beginning, you know, maybe you want to look at, you know, maybe just a couple of easy things. Denials, length of stay, maybe readmissions. You know, keep it simple. Set your baselines. So this is where we are at this point in time, and this is where we want to be. This is our target measure. Now, you also want to know, I actually had a boss ask me this. Do I want that outcome to go up or down from the baseline? So I'll show you how we did that for that boss. Select frequencies. How often am I going to reassess or recalculate that outcome? And make sure, I'm going to say it again, make sure each outcome is measurable. Okay, I know my graphics are not the prettiest sometimes, but this is part of a report card. So what you have, it's really simple. Up top here on the yellow, I have length of stay, and what I included there were inliers only. So, and you define what an outlier case is. So if you say a length of stay greater than seven days is an outlier, or 15, or 30, whatever, that's up to the hospital to decide. But those long stays are going to skew your average. So something to think about, inliers only. And then I broke it down by medical specialty. And then the next column, you see baseline. So what is the length of stay at the point in which we begin? So, you know, it might be you set this up for January of the year. So you want your baseline based on the prior year's performance. Your target, maybe the hospital wants to reduce length of stay by .2 this year. So you can list your target for each of those medical areas, and then fill in your month by month. You might also want to report on long stay discharges, discharges with lengths of stay greater than seven days, and what they are in terms of percent of total discharges, and then patients remaining with a length of stay greater than seven days. That helps you kind of chip away at some of those longer stay patients. And then if you look way over to the left, desired direction. Yeah, so you want all of those to go down in this example. Okay. And then readmissions. I know this is so hard to read, and I apologize, but Medicare readmissions in less than 30 days, heart failure. One of the things that I find helpful is, I don't want to just say we had 74 heart failure readmissions. I want to say we had 74 heart failure readmissions of a total of 900 heart failure patients. That's where you get your percent. And to me, that says a lot more. Just a plain number doesn't mean anything. It has no context. So doing a percent, I think, is valuable, and AMI and pneumonia are there. All Medicare readmissions against all Medicare discharges, all Medicaid readmissions, and all payer readmissions. Again, these are my choices. You may want to look at something different. And we're going to look at other ways to look at readmissions shortly. Denials. So for denials, because everybody's so hot to trot on denials because they mean money, you can report open denials by reason. And reason is really important. If you're taking your denials from finance, what finance does is they take all clinical denials or medical denials and they lump them all together. So you don't know whether it's a continued stay. You don't know whether it's a medical necessity on admission. You don't really know. So what we do in case management is we break it down to the actual reason. So it's helpful if a nurse in the case management department, remember we talked about that audit and appeals case manager? This is a good person to look at those denial letters and try to figure out what kind of a denial and what reason and then keep that in a database. So first you have open, what's currently in the queue to be appealed. And then overturned in the next yellow line, overturned denials by reason in days. So these are all in days. And then percent of all denials overturned. Upheld denials by reason in days, the next yellow line. So how many did I overturn and then how many were upheld? When you say upheld, it means we lost the appeal and percent of all denials upheld. Total patient days, total denied days gives me all denials as percent of patient days as I mentioned before. So it gives you a much clearer view of exactly what's happening with your denials. So you don't want to drown in data. You want to have data that you can actually use and turn into information. They are not the same thing. Data is just data. But data becomes information when you analyze it. You want to look at it methodically and in detail. And I've told you a lot of details today. So you want to look at it that way. You want to critically study it. You want to assess for the quality of the data, evaluate for importance and value, and report it in a usable format. So you've got all these different elements that you want to study when you look at your... Once you've got that answered, then you don't have to do that every time. When you're ready to report, you do want to ask who the audience is, who we're accountable to, who's going to get this information, and what measures are appropriate for this purpose. So if you're going to, obviously, a readmission meeting, you know, that's not going to bring all of the case management information. Even if you're going to use your report card for your UR committee, which I strongly recommend, even the UR committee doesn't necessarily need to see everything every time. You may want to pull pieces out to discuss at the UR committee and maybe to use for a project as an offshoot of the UR committee. So what information does this particular audience want? Are there trends that are apparent that you can share? Are there trends that are apparent that you can share? Whether they be good or bad, even if you're not seeing improved results being sustained over time, that's even more reason to share the data. I also gave you on this slide and the next slide some other ways to report on readmissions. If this is a big deal in your hospital, case management can take an active part in reporting readmissions in a number of different ways. So if you're looking across the very top with me, admissions year-to-date, readmissions year-to-date, percent of readmissions year-to-date. So that tells you of all your admissions how many were readmissions. And then same thing for prior year. So admissions last year-to-date, readmissions last year-to-date, percent readmissions last year-to-date, and then the percent change from one year to the next. On the bottom left, I just gave you an example of a breakdown of specific types as percentage of all readmissions. So I just pulled out nursing home, heart failure, AMI, pneumonia, and hips and knees. On the right, percent of admissions and readmissions by category. So nursing home admits, nursing home readmits. Again, you can get that percentage. Heart failure admits and readmits and so forth. So this data also, you know, can tell you, oh, look, a large percentage of our patients are coming in from a nursing home or not, or a particular nursing home maybe, or, you know, anything of that sort. Or we have our biggest problem with pneumonia. Probably not, but maybe it's hips and knees. Maybe that's why that cost was high. You can also look at your readmits by payer as a percentage of all readmissions. So while we're only required or we're only being penalized for Medicare, I still want to know what's going on with my other patients because, you know, we don't want to see a lot of readmissions for anybody. And remember, we looked at those other financial measures. So you can kind of do the same thing. You can put your metric. You can do your prior year results, your benchmark, and so forth. Easy enough for reporting purposes. And then there's the dreaded executive summary report. Yes, yes, yes. So when you report out to the executive team or to your boss, if you're the one doing that, you want to include changes in the data, be they positive or negative. You don't want to just come with a stellar report card every time because everybody knows, you know, while that's good to know, it's not valuable in terms of making things better. You want to explain your trends. So maybe you want to have a combination of some stuff that's doing well and then some stuff that's maybe not doing as well and then any performance improvement plan you might have in place to correct or improve that negative trend and who the other key stakeholders would be because, again, it's not just us on most of this stuff. So you want to engage with those other departments and disciplines that may have an impact. So, you know, it might look something very simple, something like this. So here I chose in-liar length of stay, percent of patients discharged with a length of stay of greater than seven days with reasons, overall readmit rate, and percent of days denied in dollar amount. And I guarantee you, if you pick something like this, this is what folks want to see because this is where the rubber meets the road in terms of money. A couple of other reports, denial report. So let me just walk you through this quickly. Again, not real numbers. So if you go over to the way over to the left column, I have recoveries. So we have February this year versus February prior year and whether we've improved. So in this case, we have improved by $300,000 or 213%. So that means our recovery rate went way up. Next line, final denials went from $165,000 to $154,000, which was favorably $11,000 or an improvement of 7% or went down, I should have said. Okay, and then you can do year to date, same thing. And then initial denials as a percent of patient days based on date of service, okay, you can see those, and then all cases pending. Now why do I want to put all cases pending? Mainly because a lot of dollars that are out in that queue, remember we looked at the box where it said initial denials received, those are all out in the queue being evaluated. And so we may win or we may lose on those, we have a 50-50 chance, so we want to let folks know that this is all the money that's out there at risk right now. And then this is an initial denial report, this is reporting denials based on the date the denial was actually received. Sometimes people report based on date of service, and sometimes they report on date received. This one is date received, but all the different reasons, again, having a nurse, look at those denial letters, and come up with the appropriate reason. So here we have continued stay, admission, pre-cert, care level reduction, delay in service, and other. And so you can see whether we did better or worse month over month and year over year. This one's my favorite, I have to say. But this one coming up now is pretty good too, love the pie chart. People love pie charts, so again, you have to know your audience. What's going to really jazz them up about your denial report? Well it might be a pie chart, you never know. So here we have all denials received in dollars, cases recovered in appeals, which was 41.1%, lost 42.2%, and open cases currently 16.7%. And a blowout pie, which really quickly tells you the story. The other thing I would, as a director of case management, I would always get asked about were home care placements, particularly from specific agencies. You're not sending us enough patients, you send all of the patients to XYZ and you don't give us any patients. Well I said, the only way I can disprove that is with data. So we started tracking not only how many patients went to specific nursing homes, but also whether they were a new placement or a return. Because home care typically wants new patients, not necessarily just returns. So you know, you can see pretty quickly that agency C is getting a lot of new patients, which is the orange. And I am so sorry agency D is way over there, I can't figure out how to move it. But there it is. No reason why it's over there. Well I guess there is a reason, because their orange is lower than their blue. Maybe that's why I did it. And then this one, really important too, causes of long stays. So if you decide you're going to identify long stays as patients with a length of stay greater than or equal to seven days, and then those are your excess days, and you want to understand the reasons for those excess days as we talked about earlier, were they avoidable or were they not avoidable, I put in the box for you all the different reasons why a patient might stay longer than expected, and you can decide were these things that I could fix. Now some of these probably not. So were they acute, clinically appropriate to be hospitalized? And I've looked at this data for different populations of patients many times, and most of the time the vast majority of patients who exceed their expected length of stay, who have those excess days, are clinically appropriate to be hospitalized. And that tells a big tale when you report it that way. Or did I have a placement delay because you couldn't get the service or the bed? Payer issues, you're waiting for approval. Patient and family delays, psych-related, you can see how these bump up with your avoidable delays, unavailable psych bed, legal guardianship pending. So again, lots of different reasons why patients may exceed the length of stay, the majority of which are outside of our control, and yes, they have something to do with discharge planning, but it's not something that's because somebody didn't do their job quickly enough or something of that sort. So all of your different items begin to correlate with each other. And when we had looked at all the different kinds of avoidable delays, one was system or hospital services. So this one very quickly tells me in the quarter, meaning three months' worth, we see 56% of the delays in that quarter were due to the cath lab delays. Again, these are all made up. And then percent delays occurring on the weekend. So yeah, my overall thing might be cath lab, but what's happening on the weekend? Because many times we have a lot more kinds of delays on weekends than we do on weekdays. So I also recommend that you split out weekdays from weekends when you're looking at your avoidable delay data. So here we have first quarter versus second quarter. So on the weekend, it's not cath lab, it's CAT scan that jumps up. So something to bring back to your radiology director, see what you can do about that. And then hospital, you know, you can put these sometimes in different categories. This one is, you know, just a couple of examples, MRIs and OR bookings. External resource availability, this one can really add up to a lot of days. So if you look at 96 days there in the dark orange, that's no aid available. So that's typically a Medicaid patient who has to go home with a home attendant and there's no one available, and look at how those days add up. And then no facility to accept the patient, 87 days in the third quarter. And then no psych bed available, 50 days in the third quarter. So that's a lot of days, and those are days that we can't fix. So, you know, you want to report them. You want to say, look at all these other things that are impacting on length of stay that cannot be repaired by the case management department. And then, of course, your patient and family stuff, patient issues that may result in inability to get the right facility for the patient, 99 days, blue there, guardianships, no insurance, you know, lots of different stuff there, lots of days. And then payer, the classics, right? Managed care approval delay, processing Medicaid form delay, workers' comp delays, the dreaded workers' comp that we all have difficulty with. So my goodness, delays in processing Medicaid forms, 102 days. Managed care approval, 92, I'm sorry, that's workers' comp, 75 and 92 on the workers' comp. I think if I'm seeing the colors right, a lot of days there, okay. And then the good old provider, surgical consult delays, MD, generic MD delay there, delay in speech and swallow. So this is, again, not to be punitive, but to take this data and bring it to the right leadership person and see if, you know, there's an opportunity to make it better because sometimes people don't even know there's a problem until you bring it to their attention. Now this graph, also very busy, but it's kind of an important graph. So this is discharges and admissions by day of the week. So discharges are the pinkish line graph and admissions are the yellow line graph. And so you start to see what we call a seesaw pattern. So if you start on the bottom left, Sunday, Monday, and you start to see your discharges going up, Tuesday, Wednesday, now we go up, Thursday more, Friday we peak, and then on Saturday we drop back down again. Same thing with the admissions, they peak and then they drop off, very much correlated with your admissions. So admissions and discharges, seesaw, and you can predict, you're going to have tons of discharges at the end of the week, and then your admissions start to creep up and the pattern just keeps repeating itself. And when you have a seesaw pattern like this, it's really not what you want. You want something that's a lot less jagged. You want something that's more linear. And so what can we do as a hospital to even it out, to have more discharges at the beginning of the week or the middle of the week or whatever the issue is. And again, this data, very helpful. You also want to know, as a case management department, what your finance department has budgeted for average discharges per day. And I guarantee you, they have that number. So in this example, we put 42 discharges a day were the budgeted number of discharges. And that's the blue line going right through the middle of it. So you can see how half of the time, at least, we're underneath that 42. So again, just another way to look at it. I like this one. Even though it's busy, it's a good one. So you want to understand your key performance indicators, what they mean, how to measure them, know what process changes will get you to your targets. Sometimes it's a matter of simplifying and streamlining your workflow. Manage your workload to optimize existing resources. So that all gets back to who does what, where, and how. So you really want to have a department where your positions are used most effectively. Staff development. You want to keep staff informed, you guys. Everybody needs to know how we're doing. If you don't, it's like no news is good news. So if the staff doesn't know where performance improvement opportunities lie, then they're just going to keep doing things the way they've been doing them. And then know what additional resources you may need. Yes, boss, I'm going to do this, but in order to do this, I'm going to need an extra social worker. So as case managers and social workers, you need to, one, know what your outcomes are supposed to be, and then be very involved. Because you're closest to the action, as I always say. You have the information, the expertise, you understand clearly what the issues may be. So you can take ownership on some of these things and help your bosses with follow-through on solutions and results. And this is something good to do if you're, if you've been a case manager for a while and you're looking for a new challenge, this is something you can get involved with. And this would be a long-term commitment. You also want to ensure efficient utilization of resources. This is part and parcel to your daily work. You don't want to give the patient more than they need or less than they need at any point in time. And then constantly be incorporating new knowledge and skills. Things are always changing. And you want to make sure that you, you know, maintain a level of expertise. But since we were talking about data today, I just want to say, without data, you're just another person with an opinion. So anytime you find a problem or you find an opportunity, you want to have that helpful data that's going to make your point for you. The data speaks and maybe you'll actually get what you need. So a lot of information here for you in our final webinar in our series and references for you as well. I hear this book by Tony Sesta is a pretty good one there, number three. So I don't know, Lindsay, they might want to pick that one up. I haven't mentioned it before. I've been very good, but there it is. And okay, well, I am so thrilled that you all were here with us for these five weeks. And I'm happy. Lindsay, if there's any questions, I'm here. Perfect. Thank you so much, Dr. Sesta. I'll do just a couple of closing remarks. And while I'm doing that, if you do have any questions, please go ahead and be typing those into the Q&A option found there at the bottom of your Zoom window. Or if you don't see that option, you can, of course, type any questions that you have into the chat as well. And of course, it doesn't have to necessarily be applicable to today's presentation. But if you've been holding a question, maybe from one of the previous sessions, I'm sure Dr. Sesta wouldn't mind if you go ahead and type that in and she'd be happy to address that live now as well. Okay, so I did go ahead and perfect. I'd go ahead and post some information there for you on the chat. If you've joined us for the previous sessions, then you are accustomed to this routine. But just a reminder that you will receive an email tomorrow morning. But just note that it does come from educationnoreplyatzoom.us. And because it comes from that Zoom email address, those emails seem to often get caught up in your spam or possibly your quarantine junk folders, that kind of thing. So if you don't see that email in your inbox in the morning, you can just check those additional folders. And then if it's still not there and you would like to access the recording, you can just use the same Zoom link that you used to join today's live presentation to also access that recording. And just remember that the link to the recording of each session in the series is available for 60 days from the date of that live session. So you should still have access to all of the sessions in the series. And again, they will all be available for 60 days from the date of that live session. You will need to click on that Zoom link and enter your information that will prompt an email to come to us for approval of the recording access request. And then you will get a follow-up email from Zoom confirming that that request has been approved. And again, you will then have full access to the recording. Just a comment here saying thank you so much for five great sessions and we have received just wonderful feedback from you all. So let me thank all of you for joining us throughout. As Dr. Sesta said, we started kind of in the winter and now we are in the early to late parts of the spring. And so we're just so thankful for you all joining us. And as always, Dr. Sesta, for your time and all of the wonderful information that you shared with our attendees, we just continue to receive such wonderful feedback and we just greatly appreciate you sharing it with us all. Well, I thank you so much for inviting me back and always have a great audience. And I just want to add, Lindsay, if anybody, you know, comes up with a question down the road, could be a month from now, you know, please don't hesitate to email me. And I will try to respond. And if I don't know, I'll get the answer for you. And that is above and beyond the call of duty for you, Dr. Sesta. So we just appreciate you being willing to do that. And I do, everybody can see your email address there on the screen. And so you will have a copy of the slides. It'll be in that email tomorrow, but I did go ahead and provide that there for you on the chat to have as a resource now as well. And you can always email us at education at gha.org. If we can help answer any questions or possibly get a question over to Dr. Sesta, we're happy to do that as well. Okay. Just lots of comments here saying great content and thanking you so much for providing the information. So I will echo that one more time and just thank you all again for joining us. We look forward to having you back with us for future sessions. And again, if we can be of any assistance, please don't hesitate to reach out to us at education at gha.org. Thank you so much, Dr. Sesta, and we will talk to you soon. Have a wonderful weekend. Thank you so much. Bye-bye.

Dr. Tony Sesta

Key Performance Indicators

KPIs

Case Management Departments

Patient Satisfaction

Organizational Objectives

Cost Avoidance

Healthcare

Financial KPIs

Clinical KPIs

Readmission Rates

Cost Per Case

Hospital Readmissions Reduction Program

Medicare Spending Per Beneficiary