Informed Decisions Affecting Healthcare Management, Case Study Example

The *Dyess County Clinic located in Atlanta, GA has been in operation since 1980 and serves about 5,000 Medicaid or low-income patients per year.  It has a staff of seven doctors, four  registered nurses (RN), and two licensed practical nurses (LPN).  Our operating hours are Monday – Friday (7:30 am to 5: 00 pm), Saturday (9:00 am to 2:30 pm).  However, due to the economic recession, we are cutting our budget by 15% using the Informed Decisions Toolbox, a six-step program (framing the question, finding sources, assessing the accuracy, assessing the applicability, assessing the actionability, and determining if the information is accurate).  It helps managers make strategic choices.  (Rundall, 2007, p. 325). 

According to Tina Samuels, “Free clinics have a huge impact.  There are estimates that over 90,000 Georgians were seen in 2004.”  The Informed-Decision Toolkit was devised by Herbert Simon sixty years ago and addresses barriers such as “time pressures, perceived threats to autonomy, the preference for colloquial knowledge based on individual experiences, difficulty accessing the relevant evidence base, reliance on external consultants and others to determine the quality of the information, and lack of resources (Rundall et al. 2008).  (Rundall, p. 327).  Today, decision making is still being studied.  According to the Harvard Decision Science Laboratory, “Rather than dictate how decisions should be made . . .  seeks to understand how decisions actually are made in the real world.” (2010)

In 1965, an amendment to the federal Social Security Act was implemented.  According to the Georgia Department of Community Health’s website, the following was enacted:

* The Dyess Clinic is not an actual clinic, but reflects the services, guidelines and operating procedures of a typical clinic in Georgia.

It established two major national health care programs, Title XVIII (Medicare) and TitleXIX (Medicaid).  Georgia began serving members in 1968 with expenditures of $28 million.  In fiscal year 2006, Georgia Medicaid serviced 1.5 million members with $5.9 billion in state and federal funds.  States administer their programs under federally approved state plans.  Georgia Medicaid currently receives $1.63 in federal funds for every $1 of state funds.  Medicaid reimburses health care providers for services to eligible members. (Medicaid section, 2010)

From a statewide health policy standpoint, the Medicaid program is the largest division of Community Health.  It provides health care for children, pregnant women, and people who are aging, blind and disabled.  For individuals who receive Supplemental Security Income (SSI), the income limits are as follows:    Individual – $674 per month ($8,088 per year); for couples, the monthly income is $1,011 per month ($12,132 per year).  These figures vary reflecting those individuals who can stay at home, but require community care services or are living in a nursing home.  Individuals who are terminally ill and are not expected to live more than six months may be eligible for coverage.  Children who meet the standards of the old AFDC (Aid to Families and Dependent children) program are also eligible depending on family size (1 to 4 persons) and household income ($235 per month to $500 per month).  Pregnant women who meet the respective requirements are also eligible.

The goals of the Medicaid program and the Dyess Clinic are as follows:

1) Provide health care coverage to low-income residents, 2) Offer special community-based coverage for certain disabled and elderly older populations, 3) Extend supplemental coverage to lower income Medicare beneficiaries, 4) Defray the high costs of hospital care for lower and moderate income Georgians. Other services provided by Medicaid include:  Burial exclusions, emergency medical assistance, long term care and independent care waiver program.

Our disease management program consists of 98,000 members of the Social Security Disabled population of Medicaid.  It addresses diabetes, congestive heart failure, asthma, coronary artery disease, hemophilia and schizophrenia. Since the program’s inception in 2006, it has saved Medicaid $40 million.

As the British Journal of Medicine reports [Clinical methods guidelines should include] “methods for taking into account patient’s preferences.“  (2010)  After considering the special needs of our patients and learning about the Informed Decisions Toolbox, I have talked with our staff and we have agreed to develop a questioning organization culture.  Managers will question important decisions and become active in journal clubs and attend seminars.  Clinical staff and management staff at all levels understand that evidence-based management involves people, not just rules and regulations. As a group, we have established a committee to create decision-making guidelines and follow up on the due diligence that is essential for major operating decisions.

Additionally, we have gotten feedback from 5,000+ members of our community and patients regarding their input for upcoming changes.  The three-page questionnaire (120 questions) revealed patient concerns, areas of improvement, and possible solutions.

After considering the suggestions from my staff, patients, and using the Informed Decisions Toolkit, I realized the question was not what services should be eliminated, but what services should be retained.   This objective format prompted me to find sources of information such as the Center for Health Management Research and the Educational Trust.

The following services will be eliminated or introduced:  Our disease management program will be modified.  It will entail an educational format which will allow us to reduce our staff and expenses by 3%.  Services for illnesses that can be properly managed at home will not be delivered at the clinic.  For example, diabetes patients will be assigned to a case worker who will refer them to the local diabetes associations and support groups to discuss meal planning and exercise regimens.  The decrease in use of equipment and medical supplies is 4%.

Two nurses (one RN and one LPN) will be terminated reflecting a 2% decrease.  This choice will reflect Step #4 (context of the decision).  A review of academic journals citing clinics with a reduced staff (Step #3 – evaluating the collected evidence) said that their productivity was not greatly affected.  Cross training (knowledge transfer) of staff facilitated quality care.

The clinic will be closed on Wednesdays, (4 % reduction).  The wages for the hourly workers —  two LPNs will be reduced by 2.0%).  Step #5 – Actionability revealed that our patients could still be served properly with less clinical visits.

Managers often cite the four As (accessibility, accuracy, applicability, and actionability) as critical to useful evidence.  The implementation of the program addresses all of these concerns as we attempt to “balance the principles identified by Simon with recent developments in the resources available to assist decision makers” (Rundall, 2007, p. 326).

References

BMJ Publishing. British Journal of Medicine. (2010). Checklist Guidelines. Retrieved from http: //www.resources.bmj.com/bmj/authors/checklist-forms/clinical-management-guidelines

Georgia Department of Community Health. (2010). Retrieved from http: //www.georgia.gov/00/channel_title/0,2094,31446711_31944926,00.html

Harvard Decision Science Laboratory at Harvard Kennedy School. (2010). What is Decision Science? Retrieved from http://decisionlab.hardvard.edu/what-decision-science

Rundall, T.G., Martelli, P.F., Arroyo, L., McCurdy, R., Graetz, I. (2007).  Decisions Toolbox:  Tools for Knowledge Transfer and Performance Improvement.  Journal of Healthcare Management. pp. 325 – 342