EXECUTIVE SUMMARY
Case managers may be working longer hours and have more responsibilities to help their hospital comply with health care reform initiatives, but before rushing to the C-suite to ask for more staff, case management directors should take a hard look at the roles and responsibilities of the department, experts say. They recommend:
- Look at your staffing ratio and determine if it is appropriate for your case management model and if it is in line with staffing ratios at similar hospitals with similar models.
- Make a list of all the tasks that case managers are asked to do and break out those that don't affect outcomes or cost of care and those that don't require licensure. Get these assigned to other employees.
- Before you approach management to ask for more staff, do your homework and have hard data to back up your request.
- Consider hiring case management extenders to take over clerical tasks and free up case managers to work at the top of their licenses.
“There has been a lot of attention paid to value-based purchasing, patient satisfaction, accountable care organizations, and population health management, and it all is centered around case management and managing cost across the continuum. Hospital officials are beginning to see that a good case management department makes the difference between sometimes being in the black and being in the red,” says Brian Pisarsky, RN, MHA, ACM, senior managing consultant at Berkeley Research Group, with headquarters in Emeryville, CA.
The problem is that every time there’s a new initiative from the Centers for Medicare & Medicaid Services (CMS), case managers get another task added to their responsibilities, points out BK Kizziar, RN-BC, CCM, owner of BK & Associates, a Southlake, TX, case management consulting firm.
“Historically, if the hospital administration doesn’t know what to do with something, they send it to case management. All over the country, I still see case managers who rarely talk to patients or meet the family because they are too busy with assigned tasks. How can case managers develop a workable discharge plan if they never meet the patients?” she adds.
Despite all the attention given to case management, decision-makers at some hospitals still see case management as a cost center, Kizziar says. “Often case managers are used only to meet regulatory requirements, and this doesn’t do anything to affect outcomes. It all rolls in together. We are so busy trying to meet regulatory requirements that we are too busy to engage the patient and family to be an active part of their own care,” Kizziar says.
Case managers often complain about working long hours and not having time to get everything done, but often it’s not a matter of inadequate staffing. It’s a matter of roles and responsibilities, Pisarsky says.
“When the case managers are asked to do more tasks than they can handle, it becomes difficult to prioritize their work. Once their priorities become muddled, the important tasks get dropped, and this often has a negative impact on revenue. At some organizations, utilization review doesn’t get done or pre-certification doesn’t happen, or because nobody has had time to find out about a patient’s home situation, you find out on the day of discharge that she has no place to live and she has to stay at least another day. All of this adds up to loss of revenue for the hospital,” he says.
Before making the case with the C-suite to add staff, take a long, hard look at the department and analyze the roles and responsibilities of existing staff, Pisarsky advises.
“Throwing more people at the problem is not always the answer. If the process is broken, you have to fix it or adding staff won’t change the end result,” he says.
Start the process by understanding what your staffing ratio should be, says Beverly Cunningham, RN, MS, consultant and partner at Dallas-based Case Management Concepts. Staffing depends on the case management model, she points out. She recommends a ratio of one case manager to 15 patients if the case managers are doing utilization review, basic discharge planning, and care coordination and seeing every patient. Social workers should have a caseload of 17 if they are intervening on 40% of the cases, she says.
Other models would require a different case manager-patient ratio, she adds.
Compare your case manager-to-patient ratios to those in other hospitals with similar models, Pisarsky suggests. “If your department’s ratio is close to the national ratios, look carefully at why you need more staff,” he says. It could be that case managers are being asked to do things that they shouldn’t be doing, he adds. “Could those tasks be moved to another department or a case management assistant be added to do these administrative duties?” he asks.
Cunningham suggests analyzing data in the five areas where case management interventions can make a difference. These are denials, length of stay, avoidable days, cost per case, and readmissions. Determine if any of the areas are trending upward.
Give particular attention to cost per case and readmissions, because they will affect the Medicare spending-per-beneficiary metric that the Centers for Medicare & Medicaid Services has added to its value-based purchasing beginning in 2015, she adds.
Compare your data with national benchmarks for length of stay, cost of care, and readmissions. “If the department has best-practice staffing, these metrics should be within the benchmarks. If any of these areas are trending higher than the national benchmarks, focus on those areas and determine if it’s because you don’t have adequate staff or for another reason. Then predict what you can do to impact the trends,” she says.
“There’s no magic formula. Case management directors have to be able to make a reasonable calculation of where they can make a difference,” she says.
For instance, if the cost per case is going up, look at what case managers can do to make an impact. “They can cut length of stays, decrease avoidable days, and decrease readmissions. They all play into the dollar amount in Medicare spending-per-beneficiary. All are interrelated and can be impacted by better discharge planning,” Cunningham says.
Make sure your case management staff are doing case management and not 20 other things, Kizziar says. Identify all of the tasks your case managers are doing that benefit no one in terms of outcomes, patient satisfaction, and cost of care. Most of these will be clerical tasks, such as printing documents, faxing nursing homes, or filing patient records, Kizziar says.
Determine how many hours the case managers spend each week on these tasks that are not part of the case management process. Break out how much on clerical tasks and how much on utilization review, she says.
Determine if the right people are being utilized in the right role, Pisarsky adds. “Just because a nurse case manager is in the chart, that doesn’t mean they should be doing documentation improvement or completing medication reconciliation,” he says.
Develop responsibility grids that specify the primary duties and expectations of the case managers and work to eliminate tasks that are not on the grid, Pisarsky suggests. For instance, filling out workers’ compensation papers or completing sick notes for patients is not the responsibility of case managers, but they are asked to do these tasks in some hospitals, he says.
Build a dashboard around key performance indicators of the case management department and set goals for each. Look at the results monthly or daily and create easy-to-read graphs showing progress. “If you’re not moving toward the goals, there’s no question that you need to change directions or processes. If you are not measuring it, you are not managing it,” he says.
If the problem is that case managers are doing tasks that don’t require their level of expertise, reorganize the department, Pisarsky says.
Adding more case managers isn’t the solution to everything, Cunningham adds.
“Hospitals need to have a strong case management director who can manage and mentor people. The director must understand the business case for case management and that case management is a clinical business department. Physician involvement and family involvement are also important. There are a lot of variables that impact the metrics,” she says.
For instance, if your goal is to decrease length of stay, look at avoidable days and drill down to find out why patients stay longer than expected. If it’s primarily a physician issue, get the chief medical officer involved, Cunningham recommends.
If denials are going higher, drill down to determine whether it’s because you don’t have adequate staff or for another reason, she adds.
“Many case management departments do not manage their own denials. They are handled by someone in revenue integrity or finance. Case management departments need to have an expert who understand denials processes related to case management and the nuances in denial patterns for individual payers and can educate the staff about what each payer is looking for,” she says.
If you really need additional staff, determine if you can cover the responsibilities of the department at a lesser cost, Pisarsky says. Consider hiring case management assistants or referral coordinators to assist the case managers in getting the work done but at a lower salary than a licensed individual would be paid. (For details on case management extenders, see related article "Have data ready to back up your need for more staff, experts say".)
Extenders can set up transportation, order durable medical equipment, and make referrals to post-acute providers, Pisarsky says.
“Having case management extenders in the department gives the licensed staff the time to do the work that needs their expertise, which is case management and discharge planning,” he says.
The department must have adequate staff that are assigned appropriate responsibilities, experts say.
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