Case management models, not staffing formulas, dictate caseload
Variations in functions make benchmarking difficult
Case managers often attempt to benchmark caseloads, but variation in the functions case managers perform can make it difficult to come up with reliable numbers. "It is a difficult problem, because what case managers do in one facility is different from what they do in another," says Patrice Spath, ART, BA, president of Brown-Spath & Associates, a health care quality consulting firm based in Forest Grove, OR. "When you try to develop caseload ratios, you often end up with apples and oranges."
For example, some case managers perform utilization review and correspond with insurance companies, while others have separate utilization review teams that perform those tasks. "That is probably one of the most significant differences in terms of caseload," Spath says. When case managers don’t perform these tasks, they have more time to manage cases, she says. On the other hand, when the case manager does perform utilization review, it can minimize duplication. For example, two people may be looking at the chart and trying to find the same pieces of information.
While there are pros and cons to each approach, Spath says she leans toward having case managers focus on the clinical tasks they are trained to do and use medical records professionals such as utilization managers to review charts, collect data, and make phone calls.
Whatever the case, it is important to remember that you can’t benchmark effectively unless you know what case managers do, Spath says. If it turns out that a limited number of case managers are responsible for a large number of patients, it may be necessary to transfer some of their responsibilities to give them more time on clinical aspects.
"Benchmarks are helpful in a general sense in that they give you a place to start, but regardless of the hospital or setting, you have to look at everything, from the care management process to the staff activities to the organization structure, and to the optimum outcome goals," says Julia Rieve, president of CQI Healthcare Management Consulting in San Diego.
According to Rieve, redesigning a hospital case management program begins with evaluating the duties of the full-time case management and support staffs and identifying the case management model that facility managers are considering. It is not uncommon to find case managers saddled with clerical tasks for which they are overqualified and overpaid, she says. "I want to see if there are duties that can be redirected to support staff so that case managers can put more focus on clinical responsibilities and possibly increase the number of patients that can be handled," Rieve says. "About 80% of the time, I find case managers who are responsible for tasks beyond clinical duties."
The patient load should decrease if case managers are responsible for tasks beyond clinical care, including utilization review, discharge planning, or DRG optimization, she says. In an acute care facility where the average length of stay is about six to seven days, a case manager generally should handle fewer cases to maximize care coordination efforts, Rieve says.
Maryellen Reilly, MS, MT, director of clinical resource management and social work at the University of Pennsylvania Medical Center in Philadelphia, says that caseload depends on several factors. One major variable is the percentage of managed care penetration, because that often will dictate the size and function of the utilization management program that is required.
In fact, one hospital was able to eliminate all of the utilization management nurses for this reason, she says. "They have no managed care, so they don’t have to talk to any of the third-party payers." Even under that scenario, Reilly says she would rather maintain the utilization management function in another department. Regardless, it demonstrates the dramatic difference between a highly penetrated market and a market where there is no managed care, she says.
"If you have no utilization management function per se in your organization, then the caseload per case manager would be very different because essentially they would be looking at issues around the continuum of care and doing the discharge planning," she explains. "They would not have the whole utilization management function."
Another factor that affects caseload is the design of the program, Reilly says. For example, she has managed programs where the case manager has responsibility for the full continuum of care, she says. "They do utilization review and quality monitoring, and they look for risk management issues as well as all the discharge planning."
On the other hand, Reilly says she also has managed other models where she has had a split nurse and social work function. Under that model, the nurse does utilization management and discharge planning to home, including setting up home care, durable medical equipment, and other services, and social workers do the more complicated discharge planning, such as placement to a skilled nursing facility or establishing contact with the community agencies.
"They are two very different roles," Reilly explains. In the first model, the caseload has to be much smaller. If the nurse case managers are supported by social work, then they essentially are removed as soon as a nursing home placement or a skilled placement is identified. "That person’s caseload can be much higher," she says.
Yet a third model would have nurses perform utilization management and social workers perform all of the discharge planning, including home care. Alternatively, Reilly says, nurses can perform utilization management, social workers can do discharge planning to placement, and discharge planning nurses can do all the home care.
"You can’t compare those three models [in terms of caseloads]," she says. "It would be comparing apples and oranges."
However, if the same functions do exist, you can make some comparisons, Reilly says. The most general rule-of-thumb ratio would be 1:20 or 1:25, she adds. "But if the case managers are only doing utilization management, you could go up to 1:60."
According to Reilly, another important factor is how involved case managers are in the reimbursement function. For example, if they call the third-party payer or manage the denial and appeal process, that department will require a lot of resources to maintain the requisite staff.
"There is a lot of clear evidence out there that suggests if you are not keeping that department well staffed and watching your vacancies, you can lose inordinate amounts of revenue. If you don’t call the payer and get the day approved, you don’t get paid for the day. It is very simple. If you are running a system that is reimbursed mostly on DRGs and you are not managing your length of stay, then you are not securing revenue sufficiently related to your DRGs," she adds.
Three-tiered system
Some hospitals have designed a three-tiered system in which bedside staff manage day-to-day aspects of a patient’s care. The second level involves patients who require more in the way of discharge planning and financial analysis, while a third level addresses more serious cases that involve multiple resources.
Reilly says her facility uses such a three-tiered system. "It is very straightforward, and it is all designed around the patient’s discharge planning needs." For example, if a 35-year-old patient requiring wound care has support at home and does not require home care, the primary care nurse can finalize the discharge plan. "There is nothing to set up because the patient is not getting services at home," she says.
The next level may be patients who require wound care and physical therapy as well as antibiotics. If patients can receive the resources in their home, the center has a clinical resource coordinator, who is a nurse, set up that care.
If patients’ needs become even more complicated and they cannot return home until they receive rehab therapy, that means contacting the external agencies and transferring insurance information and financial information, Reilly says. "That is the most complex form of discharge planning, and that is performed by social workers."
Yet another model assigns case managers to specific units such as the cardiac unit where case managers are specifically trained for those patients. Lynn Eastes, RN, MS, ACNP, trauma case manager at Oregon Health & Science University in Portland, says that between 15 and 17 patients is a reasonable caseload in this scenario.
"If you ask 15 different people their definition of case management, every answer will be different," Eastes warns. Even some specialty case managers in her facility have a somewhat different focus when it comes to discharge planning and utilization review, she adds.
"My definition of case management is fairly comprehensive," Eastes says. It includes working with attending physicians to reduce variability and making sure that patients who fit a certain protocol are placed in that protocol, she adds. "We also do discharge planning and utilization review." Eastes says her facility made the determination years ago that, with more than 17 patients, it is impossible to accomplish all those tasks with every patient. "Under that model, anything over that becomes crisis management."
Eastes’ reasoning is fairly simple. "I have nothing scientific to base that on. But if you spend 30 minutes with each patient, it basically eats up your entire day."
Rieve agrees that if the model is specialty-based, the rule of thumb is about 18 patients per case manager. However, on the surgery unit, the number could reach as high as 28, since many hospitals now have clinical paths for the more common surgical procedures, which reduces the amount of time a case manager must be involved daily. Hospital medical units generally require lower caseloads, usually 15 to 20 patients, because medical cases require more daily attention from the case managers.
Case managers working in hospital mental health units generally can manage up to 25 patients, because they usually work with social workers who handle discharge planning, Rieve says. On the other hand, a health plan or internal workers’ compensation case manager sometimes can have up to 150 patients on an active caseload, because some cases are active for two or more years and the case manager is not dealing with each case daily.
[For more information, contact:
- Lynn Eastes, RN, MS, ACNP, Trauma Case Manager, Oregon Health & Sciences University, Portland. Telephone: (503) 494-7203. E-mail: [email protected].
- Maryellen Reilly, MS, MT, Director of Clinical Resource Management and Social Work, University of Pennsylvania Medical Center, Philadelphia. Telephone: (215) 662-4000. E-mail: [email protected].
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Julia Rieve, RN, BSHCM, CCM, CDAF, CPHQ, FNAHQ, President, CQI Healthcare, San Diego. Telephone: (619) 226-4141. E-mail:
[email protected]. -
Patrice Spath, Health Care Quality Specialist, Brown-Spath & Associates, Forest Grove, OR. Telephone: (503) 357-9185. Web site:
[email protected].]
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