A. Today’s health care consumers are demanding that they receive full value for their health care dollars. Health care executives and other personnel meet customers’ expectations by focusing on improving the quality of the services they provide and by ensuring that the customer experience is desirable and rewarding. At the same time, health care executives recognize that a focus on quality care is the best way to ensure that revenues equal or exceed expenses.

B. Health care quality has become a driving force in efforts to improve delivery efficiency and effectiveness along the entire care continuum and health and human services.

C. Case management is in the crosshair of virtually every care coordination initiative launched in the past decade. Case management roles and functions have been recognized in numerous governmental reports focused on health care quality and cited as a means to enact needed changes in the delivery of health care within the United States. While not consistently referred to as case management, the mandate for accountability and improvement in care coordination has been noted to be instrumental for the improvement of health care safety and quality (Treiger & Fink-Samnick, 2013).

D. While it may be unfair to hold the entirety of case management responsible for program success or failure, it is the position in which our practice often finds itself. Our assumed strengths of whole-person care coordination, engaging the client and client’s support system in health care improvement, minimizing fragmentation and duplication of care, improving outcomes, collaborating with the interdisciplinary health care team, and supporting excellent care transitions also appear to be weaknesses as the increasing focus on measurable outcomes demonstrate little to no impact from case management interventions.

E. Although there have been numerous anecdotal descriptions of case management outcomes, objective, consistent, and scientific evidence is sparse. What does exist is difficult to compare due to heterogeneity and lack of a priori approach to evaluation. Effective Health Care Program (EHCP) findings for a comparative effectiveness review of outpatient case management programs varied. The very issue of heterogeneity was mentioned as problematic in the research process itself:

F. It is essential for case management professionals to scientifically undertake quality practice improvement initiatives, which align with individual and organizational goals. The emphasis on quality performance and outcomes measurement to demonstrate the value of case management interventions and programs has never been more important:

A. Administrative and management processes—The activities performed in the governance and management systems of a health care organization.

B. Benchmark— A standard, or a set of standards, used as a point of reference for evaluating performance or level of quality. Benchmarks may be drawn from a firm’s own experience, from the experience of other firms in the industry, or from legal requirements such as environmental regulations (BusinessDictionary.com, 2015b).

C. Care delivery processes—The support activities applied by practitioners and all suppliers of care and care products to get the product/service to the patient.

D. Clinical practice guidelines—Systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances (Institute of Medicine, 1990).

E. Clinical processes—The activities of health care practitioners with and for clients/patients, their families and support systems, and what clients/patients do in response.

F. Direct case management outcomes—The measurement or results of those activities and interventions that are within the scope of the case manager’s practice and control. Results of the case management process and interventions executed by the case manager.

G. End health system outcomes—Those performance indicators measured for the health care system overall include the following: cost of care, quality of care, health status and clinical outcomes achieved, and patient/client experience of care.

H. External validity—External validity is related to generalizing the results to settings or people other than those studied. Recall that validity refers to the approximate truth of propositions, inferences, or conclusions. So, external validity refers to the approximate truth of conclusions that involve generalizations. Put in more pedestrian terms, external validity is the degree to which the conclusions in your study would hold for other persons in other places and at other times (Research Methods Knowledge Base, 2015a).

I. Information flow—The creating and transporting of facts, knowledge, and data that make for informed decisions. The sharing of data between providers; health care team members, with payers or with patients; and their families.

J. Internal validity—It is the approximate truth about inferences regarding cause-effect or causal relationships. Thus, internal validity is only relevant in studies that try to establish a causal relationship. It’s not relevant in most observational or descriptive studies, for instance. But for studies that assess the effects of social programs or interventions, internal validity is perhaps the primary consideration (Research Methods Knowledge Base, 2015b).

K. Materials flow—The movement of equipment and supplies across systems and processes or settings.

L. Outcomes—The end results of care, adverse or beneficial, as well as gradients between the products of one or more processes. Outcomes used as indicators of quality are states or conditions of individuals and populations attributed or attributable to antecedent health care (Donabedian, 1992). Another way of describing an outcome is as a measurable individual, family, or community state, behavior, or perception that is measured along a continuum and is responsive to nursing interventions (Moorhead et al., 2013). Classifications of
outcomes include clinical, functional, financial/cost, and experience perceived.

M. Outcomes management—A technology of patient experience designed to help patients, payers, and providers make rational medical care-related choices based on their better insight into the effects of these choices on the patient’s life (Ellwood, 1988).

N. Patient flow—The movement of patients from one place to another, from one level of care to another, or from one care setting or provider to another.

O. Process—Sequence of steps, which is taken to achieve a specific goal or end result.

P. Process measure—Used primarily to determine the degree to which the process is being executed as planned. For example, “the number of patients receiving a case management assessment within 24 hours of admission to a hospital setting.”

Q. Quality—The definition of quality varies across sectors. The American Society for Quality (ASQ) notes dual meanings of the characteristics of a product or service that bear on its ability to satisfy stated or implied needs or a product or service free of deficiencies (ASQ, 2015).

R. Reliability—Reliability has to do with the quality of measurement. In its everyday sense, reliability is the consistency or repeatability of a measure (Research Methods Knowledge Base, 2015c).

S. Risk adjustment—Risk adjustment is a corrective tool used to level the playing field regarding the reporting of patient outcomes by adjusting for the differences in risk among specific patients. Risk adjustment also makes it possible to compare hospital and doctor performance fairly. Comparing unadjusted event rates for different hospitals would unfairly penalize those performing operations on higher-risk patients (The Society of Thoracic Surgeons, 2015).

T. Standard of care—A diagnostic and treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance or, in legal terms, the level at which the average, prudent provider in a given community would practice. It is how similarly qualified practitioners would have managed the patient’s care under the same or similar circumstances (Medicinenet.com, 2015).

U. Standard (of practice)—An authoritative statement agreed to and promulgated by the practice by which the quality of practice and service can be judged (Case Management Society of America, 2010).

V. Variation—Inevitable change in the output or result of a system (process) because all systems vary over time. Two major types of variations are either common, which is inherent in a system or special, which is caused by changes in the circumstances or environment (Business Dictionary.com, 2015a).

A. The Case Management Society of America (CMSA) describes in its standards of practice for case management (CMSA, 2010) that case management practice extends across all health care settings, including payer, provider, government, employer, community, and home environment. It also describes that evaluation of the outcomes of case
management practice is important in demonstrating its value to various stakeholders including clients/support systems, providers, payers, employers, and regulators.

B. This chapter describes various perspectives on health care quality and outcomes. In striving to maximize outcomes, interventions are delivered within the context of quality case management aimed at achieving client satisfaction, especially in access to and experience of care.

C. This chapter addresses case management practice, which requires knowledge of and proficiency in the following practice standards: problem/opportunity identification, monitoring, outcomes, research, and research utilization.

D. This chapter also provides case managers with an important perspective about how their roles relate to and impact quality, safety, and cost. Additionally, it shares with case managers the requisite knowledge, skills, and competency in the area of quality and safety that are necessary for successful and rewarding practice.

A. Avedis Donabedian was a physician and is considered founder in the study of quality in health care and medical outcomes research. His model of care described a quality paradigm for examining health services and evaluating quality of health care. (Donabedian, 1966)

B. When selecting outcome measures, we are attempting to determine in advance the potential effects, side effects, or consequences of our actions.

C. Outcomes measurement can assist in the demonstration of value by validating:

D. The centerpiece and underlying ingredient of outcomes management is the tracking and measurement of the patient’s clinical condition, functional ability, and well-being or quality of life. Today, however, client’s safety and experience of care have received major attention in the measurement of quality and the impact of health care services deliver.

E. Outcomes management is a common language of health outcomes that is understood by patients, practitioners, payers, health care administrators, regulators, and other stakeholders.

F. Outcomes management requires a national reference database containing information and analysis on clinical, financial, and health outcomes, estimating:

G. Outcomes management is dependent on four developing technologies:

H. One of the typical results from analysis is the detection of variation. Variation is typically measured through an outcomes management program. Variation is neither good nor bad in itself. Further analysis is required to determine what the causation is for the variation. The goal of outcome management is not to eliminate variation but to reduce it in order to produce and sustain stability in processes and practices.

I. There are two types of variation:

J. Once variation is detected, a variety of quality improvement strategies, techniques, and methods can be used to improve outcomes and decrease variation. Examples may include: