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Introduction: High-need, high-cost (HNHC) patients can over-use acute care services, a pattern of behavior associated with many poor outcomes that disproportionately contributes to increased U.S. healthcare cost. Our objective was to reduce healthcare cost and improve outcomes by optimizing the system of care. We targeted HNHC patients and identified root causes of frequent healthcare utilization. We developed a cross-continuum intervention process and a succinct tool called a Complex Care Map (CCM)© that addresses fragmentation in the system and links providers to a comprehensive individualized analysis of the patient story and causes for frequent access to health services., Methods: Using a pre-/post-test design in which each subject served as his/her own historical control, this quality improvement project focused on determining if the interdisciplinary intervention called CCM© had an impact on healthcare utilization and costs for HNHC patients. We conducted the analysis between November 2012 and December 2015 at Mercy Health Saint Mary's, a Midwestern urban hospital with greater than 80,000 annual emergency department (ED) visits. All referred patients with three or more hospital visits (ED or inpatient [IP]) in the 12 months prior to initiation of a CCM© (n=339) were included in the study. Individualized CCMs© were created and made available in the electronic medical record (EMR) to all healthcare providers. We compared utilization, cost, social, and healthcare access variables from the EMR and cost-accounting system for 12 months before and after CCMs© implementation. We used both descriptive and limited inferential statistics., Results: ED mean visits decreased 43% (p<0.001), inpatient mean admissions decreased 44% (p<0.001), outpatient mean visits decreased 17% (p<0.001), computed tomography mean scans decreased 62% (p<0.001), and OBS/IP length of stay mean days decreased 41% (p<0.001). Gross charges decreased 45% (p<0.001), direct expenses decreased 47% (p<0.001), contribution margin improved by 11% (p=0.002), and operating margin improved by 73% (p<0.001). Patients with housing increased 14% (p<0.001), those with primary care increased 15% (p<0.001), and those with insurance increased 16% (p<0.001)., Conclusion: Individualized CCMs© for a select group of patients are associated with decreased healthcare system overutilization and cost of care., Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. This work is supported by an internal Innovation Grant funded by Trinity Health. The funding organization had no role in the design and conduct of the QI analysis; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript. The authors have no financial stake in the sales or marketing of this tool. The copyright was assigned to prevent others from selling or marketing the tool. It was intended to be shared with appropriate permissions.

The interest we take in medical economics and strategy is like the one we take in politics: we may scorn politics, but it cannot be denied that it commands our entire life. For this reason, we must try to determine the conditions required to evaluate the quality of interventional neuroradiology, its operators, its practice, its advances, its teaching, and to maintain this quality. It is probably vital to the freedom of our future therapeutic decisions that we contribute effectively to this discussion before the standard is forced upon us by an exclusively economical or administrative logic. On the other hand, any advance can only be turned into progress if it is diffused and applied. There is no doubt that several levels of quality are acceptable, thus the best approach will be to look for and identify the minimum standard for quality or the limits of non-quality. We shall refrain from suggesting that the level of excellence at a given moment should be imposed upon all operators and constitute the standard level of practice. Practice is based on knowledge and competence. The most skilled surgical act cannot guarantee safe medical treatment if it is not supported by sufficient knowledge about the diseases and their symptoms. Mastership of the decision process requires a thorough vision of the therapeutic decision tree involved. Quality is a composition of global view and detailed analysis to allow a fuzzy gestion of the performance. Regardless of the plan chosen, openmindedness should be kept to allow adaptation, correction or interruption of a given therapeutic process in view of unpredicted pieces of information. Such input is a predictable possibility that should be explained to the patient prior to starting the procedure. Dealing with human beings, the attitude along with the technical management will be of paramount importance in the overall quality assessment.

Monitoring clinical outcome and its cost can improve the quality and efficiency of health care, and computers offer a cost-effective way to collect such data routinely. We report the development of a new computer system, including the initial requirements specified and experience with introducing a pilot system and then a commercially developed system in several sites. Problems met when designing, implementing, and operating the system are described, together with solutions to the problems. Costs and benefits of the system are assessed, and rules to follow in introducing computerized monitoring of clinical outcomes are suggested.

A concerted effort to decrease resource usage and length of stay without sacrificing quality of care was undertaken over a 2-year period in a high-census Burn Center. Through a series of changes in practice, substantial decreases in the costs of several high-usage items were tracked. During this period the average length of stay also was decreased. The average hospital charge decreased from $46,628 per patient in fiscal year 1993 to $33,159 per patient in fiscal year 1994. During this period there was no significant change in the patient population as measured by total body surface area percentage burn and acuity level. With the exception of significant improvement in the infection rate, there was no substantial change in indicators of quality care as measured by readmission, morbidity, and posthospital would healing progression. This cost-reduction program showed that costs can be reduced without diminishing quality of care; in some respects quality of care improved due to the practice changes that were implemented.

Development of a quality index allows a quantifiable synthesis of selected patient-care outcomes and service costs. The quality index provides potential buyers of healthcare a way to judge the costs associated with a particular level of quality and thus, compare the value of alternative services.

Background: Clinical quality improvement efforts at the Medical Center Hospital of Vermont (MCHV) led to the development of critical pathways, which show the ideal plan of care, and algorithms, which help clinicians make one of many complicated decisions within a plan of care. A synergy appears to develop when pathways and algorithms are used together., Development of Pathways and Algorithms: A steering committee supports and oversees pathway and algorithm efforts. A quarterly tracking report updating progress for all pathways and algorithms is circulated to all nurse managers, medical staff, and administrators. When combining pathways and algorithms, the pathway is created first. Algorithms are developed for trouble spots within a pathway., Coronary Artery Bypass Graft (cabg) Patients: Having developed the pathway for CABG patients, the CABG case management team meets monthly to review outcomes and variances. For example, an algorithm for managing atrial arrhythmias--the chief cause of variance for one month's results--was developed. The combination of pathways and algorithms for CABG patients has resulted in a reduction of 2.5 days for total length of stay (including 1 day on the surgical intensive care unit [SICU]), for a mean cost savings of $3,500. Re-admission to the SICU, reintubation, and mortality rates have all decreased., Conclusion: The idea of reaping the benefits of both pathways and algorithms is becoming more popular at MCHV, where teams use algorithms to improve on complicated processes underlying the pathways.

The increased demand for effective chemical dependency treatment combined with the escalating cost of mental health and chemical dependency care creates a challenge to balance the quality and cost of care. Social workers can successfully meet this challenge through individualizing client care by matching the client's needs to the appropriate level of care. Three clinical guidelines designed to deliver quality care that is cost-effective are offered: (1) Use the least-restrictive level of care most likely to initiate abstinence. (2) Assess the likelihood of treatment failure at the level of care chosen and the risks to the client if treatment fails. (3) Identify treatment failure quickly and move the client to a more-intensive level of care if significant risks are present. Combining these guidelines with an integrated treatment delivery system and appropriately trained practitioners can benefit clients, providers, and payers of chemical dependency care.

Collaborative care is a system of patient care delivery that focuses on the achievement of outcomes within effective and appropriate time frames and resources. It addresses the entire episode of illness, bridging all clinical settings in which the patient receives care. Through the collaborative efforts of multiple caregivers, a plan of medical care is mapped out that results in a clinical path. The clinical path can improve satisfaction levels for patients, nurses, rehabilitation staff, and physicians by establishing a method of reinforcement for everyone involved in efficient delivery of care.

During the past several years, the continuous quality improvement (CQI) process has gradually been adapted to the healthcare setting to improve quality without increasing costs. In traditional quality assurance models, quality is measured by the number of accidents or errors occurring. No provision is made for improving the conditions under which the errors occurred. However, continuous quality improvement focuses on the processes used to achieve a goal. These processes may be clinical, financial, or operational issues. Each step in the process is analyzed; then a plan for improvement is tested and refined. The concepts of quality improvement that have been applied in the industrial setting are now being applied in the healthcare arena. Case management and CQI are linked in philosophy and process. The steps of the CQI process can be applied to managed care plans from both a clinical and financial perspective.

Long-term care (LTC) case management has emerged as a way of addressing problems in the long term care system. Case managers serve as links between chronically ill and disabled individuals and the services these individuals need but of which they often are unaware. In this capacity, case managers address the fragmentation in the long-term care system. In guiding clients to cost-effective ways of meeting their long-term care needs, case managers also address the need for cost containment in long-term care. To ensure that case management is effectively addressing these and other problems, attention to quality is essential. However, quality assurance programs too often focus on minutiae rather than on true indicators of quality. In addition, people who are not involved in the related areas frequently make decisions about quality. These decisions impose additional, and sometimes unnecessary, restrictions on the people who are required to implement them. Total quality management (TQM) offers a new approach. In this article, a proposal is made to incorporate TQM principles into LTC case management. The LTC case management demonstration project currently underway in Virginia serves as the case study for this proposal. The proposal demonstrates a process in which quality can be built into a case management system in a way that involves the people who will implement the resultant changes. The proposal shows how case management staff members can learn to identify areas where quality is impaired and to use techniques to aid them in identifying the causes of problems. A procedure for testing solutions and for incorporating the findings into the project is described.

The changing climate within the health care system has necessitated the exploration of innovative strategies to provide quality-based cost-effective care. At a time when cost, quality, and efficiency are key issues, communication and coordination are crucial. Through a deliberate, collaborative approach to goal-directed care, case management facilitates the linking of quality and cost-effective care.

Under existing federal regulations, it is mandated that the care of all nursing home residents be reviewed annually. A four-year demonstration project in Wisconsin tested a sampling approach to nursing home resident review. The rationale for the sampling approach is that one can more effectively identify pervasive problems with resident care by an in-depth examination of a sample of residents than by cursory assessment of all residents. If problems are identified in the sample, all residents can then be reviewed. However, reimbursement for nursing home care is also influenced by level of care and given that nursing home inspectors review the appropriateness of level of care, the issue arises as to what impact a sampling approach would have on reimbursement. This evaluation compares the changes in reimbursement owing to resident review under the sampling and federally mandated, 100% review methods. The results indicate that reviewing a sample of nursing home residents may offer similar reductions in nursing home reimbursement as a 100% resident review--but at a lower cost.

Although medical-psychiatric units may have unique advantages for treating patients with combined medical and psychiatric illness, they may be costly to run, and their success requires a sound financial basis. This begins with filling beds and instituting a waiting list, and then setting admission priorities to regulate case mix deliberately to address financial as well as ethical and clinical considerations. Development of short-stay geropsychiatric evaluation services may offset financial problems associated with long stays of elderly patients requiring definitive treatment for complex conditions. Data are presented to show the effectiveness of deliberate regulation of case mix. Regarding quality assurance, key issues include maintaining documentation to meet HCFA standards for DRG exemption, and effectively integrating physical and psychiatric care, with a special focus on drug interactions and psychiatric toxicities of medical drugs. Effective multidisciplinary treatment planning meeting help in this effort, as do periodic walking rounds focusing specifically on pharmacologic issues. Denials of payment by third parties are most likely to be a problem when both the medical and the psychiatric illness are subacute but their interaction requires conjoint inpatient treatment. Prospective work with PROs can minimize retrospective denials.