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Core Measures – Case Management Drives Compliance,

Performance Improvement and Revenue

Case Management often serves as the bridge between hospital resource management and clinical care. This position has led to the diverse
scope of current hospital case management practice. Case Management departments are tasked with managing widely varied functional areas,
intervening in problem areas as they arise, and managing new issues that affect both hospital resources and clinical practice. One such issue
that has arisen in the past few years and impacted case management practice are the Core Measures reimbursement incentives developed by
the Centers for Medicare and Medicaid Services (CMS). Core Measures are the tangible forerunner of two emerging issues: public reporting of
physician and hospital performance, and pay-for-performance – compensation based on documented performance as an alternative to the
historical fee-for-service system of reimbursement.

Section 501(b) of the Medicare Modernization Act of 2003 improvement surrounding reporting compliance, documentation, and
“provides a financial incentive available during FY 2005 – 2007 process improvement. Core Measures data collection revealed scores
for certain hospitals to report to CMS on the quality of inpatient that would cause reductions to Medicare reimbursements. In January
care provided to all patients.” This was one of a series of steps to 2006, the case management department assumed responsibility and
promote public reporting of hospital quality information. began an initiative focused on improving Core Measures compliance
The Deficit Reduction Act of 2005 made Core Measures a fixture on and documentation, and developing structures for process
the acute care landscape, and improvement based on Core
defined a total of 21 measures Measures outcomes. The
for four clinical topics: Acute Brownwood Regional Medical Center results of this initiative have
Myocardial Infarction (AMI), Coree M
Cor Measur
easuree T
easur Triggers
riggers been rapid improvement in
Congestive Heart Failure CONGESTIVE HEART FAILURE Core Measures scores for all
(CHF), Pneumonia (PN), and ■ History
istory of CHF
istor
four clinical topics. In January
Previous diagnosis of AMI, clinical diagnosis of angina, diabetes, hypertension and accompanied
Surgical Care Improvement by at least three of the follo
following symptoms: 2006, prior to the initiative, the
■ Shortness of breath
Project (SCIP). Reporting of ■ Trouble sleeping overall scores for each were as
■ Fatigue
Core Measures data remains ■ Dry,
Dr hacking cough
follows: AMI was 89 percent,
voluntary. Reporting hospitals ■ Swelling
■ W
Sw
Weight gain (3 lbs. or more in one day or 5 lbs. in one week)
CHF was 48 percent, SCIP was
can now, based on ■ Anorexia 35 percent, and PN was 78
■ Dizziness
performance, gain up to percent. Proving the
PNEUMONIA
an additional two percent ■ Physician diagnosis of pneumonia effectiveness of the initiative,
of Medicare reimbursements ■ Fever (greater than 100.4° F) with no other cause
■ Leukopenia (less than 4000 WBC) or leukocytosis (greater than 12,000 WBC)
scores for March 2007 were:
for these diagnoses. ■ Altered mental status with no other cause in patients greater than 70 years of age AMI was 100 percent, CHF was
Further accompanied by at least one of the follo following:
wing:
Non-reporting hospitals, ■ Purulent sputum (or change in character of sputum) 86 percent, SCIP was 92
however, may have their ■ New onset or worsening of cough
■ Dyspnea or tachypnea
percent, and PN was 96
Medicare reimbursements ■ Rales or bronchial breath sounds percent. The improvement
■ W Worsening
orsening gas ex
exchange
change (oxygen desaturations PA PAO2/FIO2 less than 40)
reduced by two percent, as produced by this initiative is
ACUTE MYOCARDIAL INFARCTION
can hospitals that fall below ■ Diagnosis of R/O MI expected to generate
the 50th percentile. ■ Previous MI/CABG
increased revenue to the
Exhibiting signs/symptoms of an AMI:
Triad Hospitals is a Texas- ■ Chest pain hospital of greater than two
■ Jaw,
Ja shoulder
shoulder, back, or arm pain
based for-profit health system ■ Sweating
Sw percent of the Medicare
that owns or manages 51 ■ Shoulder pain
■ Pounding heart
reimbursements for the
hospitals with over 7,800 beds. ■ Nausea effected DRGs.
■ Other:
The decision was made at the
CONSULT
ONSULT SENT TO CASE MANA
ONSUL MANAGEMENT: Date:
corporate level to participate EARLY CASE IDENTIFICATION
in Core Measures data Unit
Unit Secr
Secretar
etaryy Signature
etar ignatur Charge N Nurse Signature
ignatur
The process
collection and ongoing Pa ient Label
Pat improvements targeting
performance improvement in FORM 3512; 1/2006 • WORKSHEET - NOT A PART OF THE PERMANENT RECORD
Core Measures scores at
Core Measures areas. Brownwood Regional
Additionally, the Core FIGURE A recognized that increasing
Measures initiatives in each hospital are lead by and the responsibility Core Measures performance would require concurrent management
of Case Management. of these cases. Therefore, early identification of patients with applicable
Brownwood Regional Medical Center is a 196-licensed bed facility diagnoses was critical. A method was needed to identify cases even
serving the rural area around Brownwood, TX. The Quality Department before a formal diagnosis was reached so that management for Core
at Brownwood Regional began collecting Core Measures data in 2004, Measures could begin as early as possible. Case management created
but scores consistently indicated the need for performance and implemented a “trigger sheet” (see Figure A) to include in the
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Core Measures – Case Management Drives Compliance, Performance Improvement and Revenue (continued from page 7)
initial nursing assessment. This sheet is used to identify patients whose
symptoms indicate the likelihood of a CHF, AMI, or PN diagnosis. The
trigger sheet travels with the patient’s chart and initiates a case
management referral as the patient is admitted to a unit.
The Core Measures initiative also expanded the function of the unit
secretaries to include them in the identification process of these cases.
Unit secretaries are responsible to bring cases that meet criteria as
indicated on the “trigger sheet” to the attention of the case manager on
the unit, who then assumes management of the case for Core Measures
compliance. In addition to expanding their role, the initiative influenced a
change in reporting that moved the unit secretary positions under the
Director of Case Management. This structure provides case management
control of a patient’s chart as soon as they are admitted to a unit. It also
creates a structure for managing new Core Measures as additional clinical
diagnoses are added by CMS or as the existing measures are modified.
CORE MEASURES MANAGEMENT
When unit secretaries identify a chart meeting “trigger sheet”
criteria, they attach a “gold sheet.” This is a single page listing each
Core Measures treatment step for that diagnosis, and providing a
check-off box and initial line indicating completion. The unit case
manager uses this sheet to manage and document Core Measures
compliance, actively working with the attending physician and other
caregivers while the patient is in-house. The “gold sheet” helps the case
manager prioritize and monitor each measure. The “gold sheet” used
for SCIP patients is show in Figure B.
While Core Measures are primarily managed by case management,
other services are also involved. Most of the Core Measures steps are
performed by the medical staff – by nursing or by physician order.
Respiratory Therapists conduct adult smoking cessation education
with AMI patients. Discharge instructions for CHF patients are
provided by nursing and checked by case management.
After the patient has been discharged, the “gold sheet” remains
attached to the chart for easy identification of Core Measures patients
in Medical Records. As part of the restructuring, two positions were
Abstraction Validation Tool • Surgery urgeryy P
urger
Patient Acct# MR#
Incision Time Antibiotic Time
Antibiotic Stop Time and Date Attend DR.
A individual nurse’s attention as needed, along
Surgeon
geon
Antibiotic infused within 1 hour of incision ■ Yes
Y ■ No
Prep done with clippers ■ Yes
Y ■ No
Antibiotic stopped 24 hours from surger
surgery end time ■ Yes
Y ■ No
FIGURE B
created to abstract Core Measures and mortality data. These positions,
housed in Medical Records, are staffed by experienced patient care
nurses and report to the Director of Case Management. The Abstractors
pull charts with “gold sheets” attached and abstract Core Measures
data into a vendor-purchased software. Data is submitted monthly to
CMS. Core Measures reports are available to the Director of Case
C A S E M A N A G E M E N T
Management as they are produced, providing real-time performance
improvement information.
STRUCTURES FOR PERFORMANCE IMPROVEMENT
THROUGH CORE MEASURES OUTCOMES
Reports submitted to CMS display the percentage of compliance
with and completion of all Core Measures, which is the key measure on
which incentive reimbursements are based. For example, of all the
patients treated at the hospital for that PN during that month, what
percentage had all Core Measures treatment steps completed in time
and documented?
In addition to the measures required by CMS, data abstraction
makes available additional information useful for performance
improvement. Reports are generated for each case where complete
Core Measures compliance was not achieved, displaying the diagnosis,
the specific task(s) left incomplete and/or undocumented, admitting
source, and all parties responsible for the patient including case
manager, physician, nurse, and pharmacist. Performance improvement
opportunities identified through this process are then pursued through
structures created as part of the Core Measures initiatives process.
Identified performance improvement needs are brought to
physicians and the medical staff in two ways. For each instance when a
missing physician order caused Core Measures failure, the physician is
sent a letter detailing the incident. A copy of this letter is also sent to
Peer Review. In addition, Core Measures scores for individual physicians
are abstracted and sent to each physician quarterly. These individual
scores, with names excluded, are presented quarterly at meetings of the
Physician Leadership Group, the Medical Executive Committee, Surgery
Committee, and Medicine Committee. Each physician already knows
his or her individual performance scores, and can then see them in
comparison to the rest of the medical staff. If consistently poor
performance is recognized, then Peer Review will be initiated.
Identified performance improvement needs are brought to nursing
staff through a standard Friday afternoon meeting that includes all Nurse
Managers, the Abstractors, and Case Management. The Abstractors
present any performance shortcomings by
detailing the case, missing steps or non-
Patients
atients
compliance, and the individual staff nurse
responsible. The Nurse Manager for that unit
then reviews the case and brings the issue to the
with instructions for improvement.
IMPLEMENTATION BARRIERS
At Brownwood Regional Medical Center
support from the health system’s corporate
level enabled Case Management to procure
the resources necessary to drive Core
Measures. The primary barrier encountered during restructuring and
implementation was a lack of education regarding Core Measures.
The Case Management and Quality Department staff members had
some familiarity with the system, but many of the medical and nursing
staff members did not. To address this barrier, significant (and ongoing)
educational efforts formed the foundation of the restructuring. Case
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Core Measures – Case Management Drives Compliance, Performance Improvement and Revenue
Management, Nursing, Respiratory and Physical Therapy, Pharmacy,
and medical staff all received educational in-services on Core Measures.
Physician understanding of and enthusiasm for the Core Measures
initiative was one of the most vital components of success. To increase
physician understanding of and buy-in to the system, the education
first made clear that Core Measures were developed to reflect evidence-
based patient care practices. Additionally, Core Measures performance
was not presented as a hospital outcome, but as performance
measurements specific to individual physicians, and the system of
ongoing monitoring and public comparison of scores was introduced.
Significant education was also provided for the unit secretaries
regarding their new role in Core Measures management. Educators first
provided the background of Core Measures, emphasizing the basis in
quality patient care, and then taught the unit secretaries how to use the
“trigger sheet” (Figure A). This tool was designed to allow non-clinically
educated staff to effectively identify cases. The education included the
expectations for managing “trigger sheets,” auditing their completion,
and communication standards. Unit secretaries are expected to create
case management referrals for indicated cases upon their initial
contact with the chart. They enter a referral into the computer system
which then automatically sends a fax to case management. Core
Measures outcomes were added to the performance evaluations of unit
secretaries as well as case managers.
THE FUTURE IMPACT OF CORE MEASURES
Although the Core Measures system is relatively young, it has already
been expanded by CMS – in 2005 the original 10 quality measures were
expanded to 21, and SCIP was added to the original three clinical areas.
It is likely that CMS will continue to expand the system. Triad Hospitals
monitors communications from CMS regarding expansions and
changes and regularly communicates these to its hospitals, including
Brownwood Regional Medical Center.
CMS has indicated that Pediatric Asthma will be the next clinical area
Pay for Performance and Commercial Reimbursement Contracts
In addition to CMS, commercial payers are also using quality indicators for payment incentives. The experience of Arnot Ogden Medical Center in
Elmira, NY illustrates the significant role that quality indicators can play in commercial reimbursement contracts.
Arnot Ogden Medical Center is a 212 licensed-acute-bed hospital in
Elmira, NY. The hospital began collecting quality indicator data in 2003 as
part of the initial CMS/Premier Inc. Hospital Quality Incentive Demonstration
(HQID), which was the first national pay-for-performance project of its
kind. Core Measures are driven by the Case Management Department,
and have consistently produced additional revenue for the hospital.
In 2005, Blue Cross in New York approached certain hospitals,
including Arnot Ogden Medical Center, regarding changing the structure
of their contracts. Arnot Ogden had the option to remain with their
standard contract, receiving regular reimbursement rates, or add to the
contract quality indicators that would be tied to as much as a four
percent increase in payment. Since Blue Cross patients account for 20
percent of their inpatient population, Arnot Ogden management chose
to pursue the incentive revenue.
The Blue Cross offer tied 50% of incentive reimbursements to two
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added to Core Measures, and that reimbursement for this diagnosis will
likely begin in 2008. In preparation for this addition, Brownwood Regional
Medical Center has added this diagnosis to their current Core Measures
system. Beginning in March, the unit secretaries began screening
charts for this diagnosis, and the abstractors began tracking data for
these cases. This will allow Brownwood Regional to develop a base-line
measure of performance and, more importantly, to identify areas for
improvement so that corrections can be made before performance in
the treatment of this diagnosis is tied to financial reimbursement.
As Core Measures expand, other services will increasingly become
involved in their management. At Brownwood Regional, social
workers have not yet become involved in Core Measures management.
However, they were part of the same educational process as the case
managers, and it is likely that Core Measures compliance will soon
involve this service as well, primarily in assessment of patients and
arrangement of compliant discharges.
The evolution of Core Measures will continue as performance
scores improve nationwide. The score required to receive maximum
reimbursement is continuously increasing, raising the reimbursement
curve. This trend will continue as the program matures and as
organizations increasingly seek to leverage the financial incentives
available. For organizations that successfully manage Core Measures
performance, the final effect will be increased reimbursements and
publicly reported quality performance. Patients, however, will be the
ultimate beneficiaries as they receive increasingly higher quality care.
Jacqueline McClure
McClure, RN, BHCA, FAACM, has been the Director of
Clinical Resource Management at Brownwood Regional Medical Center
in Brownwood, TX since 2004. She previously held the same position at
Shannon Medical Center in San Angelo, TX. She earned her Diploma RN
from Kaiser Foundation Nursing School in Oakland, CA, and her BHCA
from Graceland University in Independence, MO. She will complete her
MSN/MBA from Grand Canyon University in Phoenix, AZ, in December.
patient safety indicators and the remaining 50% to three clinical
indicators. The specific indicators and reimbursement weights are
chosen by the hospital and Arnot Ogden chose quality indicators that
aligned with and overlapped the CMS HQID Measures. The specific
thresholds for these indicators are determined through negotiation and
must be met in order to receive the assigned percentage of Blue Cross
reimbursements. When the contract is renegotiated annually, the
indicators and thresholds are reevaluated and renegotiated.
The CFO, CNO, and Senior Director of Continuum of Care met to
discuss which indicators to include in the contract. The quality
indicators, thresholds, and payment weights they chose are as follows:
• CHF – Discharge Instructions Provided
– Threshold: 90% – Reimbursement Weight: 12%
• PN – Oxygenation Assessment
– Threshold: 99% – Reimbursement Weight: 25%
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