Smaller CM caseloads pay off for hospital
Costs are down, patient satisfaction up
Following a successful pilot project that decreased the patient-case manager ratio, Our Lady of the Lake Medical Center in Baton Rouge, LA, hired additional staff, reducing the caseload of case managers on the medical unit and giving them more time to interact with the patients and concentrate on discharge planning needs.
Before the initiative began, medical case managers carried a caseload of 30 to 40 patients. Now, the case managers on the medical unit have a caseload of between 16 and 22.
"In the past, the case managers were spending 90% of their time doing utilization review. Now we're finding that they spend 50% of their time at the patient bedside, communicating with the families about their concerns and determining how we can intervene to help," reports Paige Hargrove, RN, BSN, CCM, director of medical management.
The hospital conducted a pilot project for three weeks on two units — the medical unit and the surgical unit — in the fall of 2004 and began the lower patient-case manager ratio on the medical unit in January 2005.
"Our goal for the pilot project was to show the benefits of decreasing the patient/case manager ratio. In order to do so, we have to show that we could save money and increase patient satisfaction and nurse satisfaction," Hargrove says.
Data from the pilot project showed a 21% reduction in variable direct costs and a potential for saving $345,000 if the lower patient-case manager ratio was implemented on the medical units.
"We were able to show management that if they would give us three more case managers, it would pay for itself. Patient satisfaction and the reduction in variable costs were huge factors in getting the additional staff approved," Hargrove says.
Higher satisfaction
The hospital chose the medical unit for the lower case manager caseloads because those patients tend be sicker and need coordination of care while they are in the hospital and more post-discharge services. Case managers on other units still carry a caseload of up to 32 patients.
"The patients on the medical unit are typically elderly patients with a lot of issues in their lives. They have one of the highest lengths of stay and one of the highest morbidity rates," Hargrove says.
The initiative has resulted in a lower average variable direct cost per case and higher patient satisfaction.
Their success continued, even after Hurricane Katrina, when the average severity and average case mix index increased and the percentage of managed care cases decreased.
Now the case mix index still is up, the average severity still is up, the capacity still is up, and the indigent population is still large.
The hospital still has an unusually high number of indigent and self-pay cases, since not all Louisiana hospitals have reopened at full capacity following the hurricane.
"The indigent population creates a challenge because many still have no housing to go back to," she adds.
When the hospital ran data on the medical unit discharges from December 2005 to April 2006, compared to the four months directly preceding it, the hospital experienced a lower length of stay and a variable direct cost savings of $103,449, while the average severity and case mix index increased.
"In the time frame after Hurricane Katrina, we had an increase in length of stay from 4.69 to 5.51. From December 2005 to April 2006, it decreased to 5.30. Our length of stay on the medical unit is now 5.23, with a case mix index of 1.13 and an average severity of 2.18, which is its highest historically," she says.
At Our Lady of the Lake, case managers are unit based and are responsible for utilization review and discharge planning, along with the social workers on the unit.
The case managers on the medical unit see each patient on a daily basis and spend time getting to know them and building trust with the patients and family members.
"This arrangement allows the case managers to be more proactive than reactive. They have more time. If they have an order for a nursing home or hospice evaluation, they can make it happen on the same day, or at least make arrangements for transfer on the following day," Hargrove says.
The case managers in the medical unit are assigned by room number. They have a computer in the area where the physicians do their dictation. All three of them work with all the physicians and go on rounds with them whenever possible.
In the past, the case managers saw patients only when they had an order for a medical evaluation for discharge planning. Now they report any issues the patient has to the physician, smoothing the way for a timely and safe discharge.
"The case managers have earned the physician's trust. The physicians seek them out because they know they are an asset when it comes to providing better patient care," she says.
The new system has been a help with insurance certifications as well, Hargrove reports.
"With fewer patients, it's easier to give a review. By seeing the patient, the case managers can get a better picture of what is going on with the patient. Just looking at the chart doesn't always give a complete idea," she says.
The goal of the project was for the case managers to round with the physician and to attend the shift handoff with the nurses, added Hargrove, who was the case manager for the pilot project.
"I rounded on every patient every day. They had my card and knew how to reach me if they needed something," Hargrove says.
During the pilot project, the hospital had only one insurance denial among the patients in the project.
Having a lower caseload enabled Hargrove to keep up with the patients and alert physicians and the nursing staff to issues they might not otherwise know.
"I was in the chart the whole day, and I knew what was going on. The bedside nurse doesn't have time to read the whole chart. At the shift handoff, I chimed in if things were going on with the patient that the nurses were not aware of," she says.
Measures of success
Hargrove found it was useful to attend rounds with the physicians because she could be a back-up for what the physician told the patient. For instance, one patient complained that she could not sleep and the physician said he would write an order for a sleeping pill but did not enter it in the chart. Hargrove reminded him, saving time for the bedside nurse who otherwise would have had to call for the order.
"Having the case manager attend rounds improved communication between the staff and continuity of care," she says.
Before the project began, the case managers met with the performance improvement team and came up with a plan and questions that would determine the effectiveness of lower case manager-to-patient ratios. The team picked two different units for a pilot project during two different times.
The team developed short questionnaires to determine satisfaction. Respondents were asked to rank their satisfaction from 1 to 5.
The nurse satisfaction survey had only two items: I am aware of my plan of care. I am satisfied with my work day. The nurses were asked to rank their satisfaction from 1 to 5.
The physician questionnaire had four questions: Was information, such as test results, available in the chart in a timely manner? Was the information accurate? Were the nurses available when you needed them? Were the orders carried out in a timely fashion?
During the pilot project, the hospital used portions of its regular patient satisfaction surveys as another measure of success.
The surgical unit experienced a mean score of 94.4 for help in arranging home services and a mean score of 80.8 for speed in the discharge process during the pilot.
Data for the medical unit indicated a mean score of 93.6 for the discharge process and a mean score of 100 for arranging home services during the pilot project.
The length of stay was reduced by 9.5% on the medical unit and by 4.6% on the surgical unit.
Following a successful pilot project that decreased the patient-case manager ratio, Our Lady of the Lake Medical Center in Baton Rouge, LA, hired additional staff, reducing the caseload of case managers on the medical unit and giving them more time to interact with the patients and concentrate on discharge planning needs.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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