Implementing an automated acuity tool for scoring case management cases and caseloads at Blue Cross Blue Shield of Massachusetts.

PURPOSE/OBJECTIVES: Blue Cross Blue Shield of Massachusetts (BCBSMA) required a statistically validated tool to understand the acuity of its case management (CM) populations. The BCBSMA management sought reliable methods to quantify the weights of case managers' caseloads, allow associates and managers to have conversations about workloads based on objective measurable data, and analyze the data to ensure that the correct populations are being targeted for CM.

PRIMARY PRACTICE SETTING(S): The tools, techniques, and strategies described in the Acuity and eQuity Workflow Solutions are suitable for all healthcare practice settings. Acuity scoring metrics are designed especially for CM settings such as independent stand-alone companies, inpatient and outpatient practices, and multistrata health plans and hospital consortia.

FINDINGS/CONCLUSIONS: The customized BluCuity assessment tool, tested in the interrater reliability (IRR) study arm of the project, was validated to a high degree of concordance in BluCuity scoring among CM raters with an overall agreement of 82% (20 novel raters, 20 cases, 190 rater pairs, 3,800 pairwise case reviews; p = .03). The BluCuity tool and workflow strategies were implemented into the BCBSMA information technology (IT) system for oncology and other CM teams in 2008. Report data demonstrated the acuities of case managers' cases, the relative case and caseload weights among a team of case managers, and the differences in cases and caseloads across CM product offerings.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Acuity-based tools such as BluCuity to access the severity, intensity, and complexity of CM cases operationalize quality assessments into quantifiable data. Acuity score reports can join other accounting and operational reports to determine appropriate caseloads, case assignments, and staffing. To assess consistency of judgment among case managers, CM organizations can implement a formal IRR testing methodology to evaluate the level of clinical assessment reliability and establish training protocols. The automated IT acuity assessment system and data outputs can be used to assess the overall weight of a caseload based on diagnosis code groupings such as oncology, pediatric, transplants, and stroke, and illustrate the intensity of services required by CM clients at different times or in different programs. Organizations that sell CM services can use the ability to score the acuity of CM cases to scale and justify the pricing of their services.