Introduction
Case management has been in hospitals for 30 years now! In the grand scheme of things, this isn’t a long time span. Despite our short longevity in the acute care setting, our roots go back to the 1920s and 30s as a community-based model for managing care for the poor. After health care reimbursement shifted to prospective payment in the mid-1980s, the need to coordinate care in the acute care setting became real and obvious. Or was it that obvious? While some hospitals across the country were early adopters of hospital-based case management, the majority lagged for years. In fact, 30 years later, some are still trying to figure out what this all means to them and to their bottom line!
Case Management in Your Hospital
While case management was evolving and changing in hospitals, the growing pains were apparent. Models, staffing ratios, reporting structures and outcome measures were variable and untested. Many hospitals still relied on the “utilization review” framework as the main structure with little focus on the integration of social work or the notion of coordination and facilitation of care. Some even went so far as to rename the department “case management” while actually changing very little else.This accompanied some bad decisions and some less than prudent ones. Some of you may still be living with some of these decisions in your hospitals today. You may be a director trying to “update” or re-engineer the department, but aren’t getting the administrative support you need. You may be a case manager who is drowning in paperwork, has too many patients to adequately handle, or is “putting out fires” all day.
Previously, we talked about how to get the case management message to the executive suite. This month, we will talk about the top mistakes that hospitals are making in terms of their case management department’s structure, processes, and outcome measures. The big question looming out there is: “What is the right model for my organization?” Unfortunately, there is no one answer to this question. The answer lies in each hospital’s needs, infrastructure and budget. However, there are some best practices now that we, as case management leaders and staff members, can embrace and adopt into our daily practice.
Case Management Department Mistake Number One: “Role Confusion or Who is Doing What?”
You may be wondering what I mean by “who is doing what?” This is probably the biggest mistake a case management department can make and has to do with something we call role blurring or role confusion. This means that the roles and functions of the staff members are undefined and blurry around the edges. Not only do the staff members themselves not know exactly what they are or are not supposed to do, neither do the other members of the interdisciplinary care team!
Most case management departments are staffed with social workers and registered nurses. These two professional groups are highly educated and competent professionals, usually with years of knowledge and experience. Despite these facts, many hospitals simply don’t use them to the “top of their license,” and meld together the roles and functions in such a way that the skill sets of each discipline are under-utilized or not utilized at all. Asking social workers and registered nurses to perform the same roles and functions results in a devaluation of both professions, as well as less productive for the organization that has hired them. Do administrators think that nurses and social workers are the same in terms of education, license, and knowledge base? Or do they think that anyone can perform the functions associated with case management? The answer to both questions is probably yes. The hospital executive you are dealing with may truly not understand the differences between what a nurse case manager does and what a social worker does. Indeed, they may think that the two professions are interchangeable, but it is up to us to redefine our roles for them when this misunderstanding happens. Some of this misunderstanding comes from a lack of appreciation of the unique skill sets that each discipline brings to the table. We are unique and different in many ways!
Registered nurses are educated in the medical/clinical components of patient care. We are educated in anatomy, physiology, microbiology, and other sciences. In addition, we get some education in therapeutic communication, family dynamics, and similar topics such as patient education. The amount of education we get in communication and family dynamics may depend on the level of education we receive to become a registered nurse. We may enter our profession with an associate’s degree, a bachelor’s degree, or even a master’s degree. We may or may not have been exposed to some of the topics related to patient care that extend beyond anatomy and physiology. This is why many hospitals are now requesting a minimum educational preparation and years of experience to become a case manager. It is no longer a “lesser” job that you take, but rather a more advanced job that requires a higher level of skill and knowledge. These skills and knowledge build on your basic licensure and educational training.
Social workers are educated in a systems approach to healthcare. They are educated in counseling, crisis intervention, and family dynamics. They are educated to see the patterns in what patients do as they relate to the home, the psychosocial environment in which they live, and their level of education and health knowledge. Social workers are focused on processes and in helping patients and their families to cope and care for themselves. Social workers may have some clinical knowledge of anatomy and physiology, but this is not where their strength lies. It lies in their ability to help patients manage life-altering events, trauma, crisis, and end of life. These skills require that social workers have the time to spend with their patients to listen to them, to counsel them, and to assist them through very difficult times and situations.
For decades, social workers had “owned” discharge planning. Social workers were the professional group that processed patients’ placement in nursing homes and completed the paperwork for home care. They assisted patients in coping with these life changes. However, they were dependent on the clinical team to “feed” them the destination that the patient was going to. When lengths of stay were long and discharge planning less urgent, this approach was fine. However, prospective payment was a game changer. Changes in reimbursement required hospitals to manage their length of stay and resource consumption, and it also required utilization management and discharge planning to become closer and more integrated processes.
In addition, community resources became more robust. High-tech intravenous services and sub-acute levels of care, among others, required that a clinical eye be placed on the discharge planning process. This focus needed to happen in conjunction with the utilization management process, not apart from it.
So, what needed to change? The owner of the discharge planning process needed to move from the social worker to the nurse case manager. This shift frees social workers to perform the skills that they went to school for, such as counseling and crisis intervention. They still needed to participate in the elements of discharge planning that required a more psychosocial focus such as long-term nursing home placements, hospice placements, or other discharge destinations requiring working with the patient and family in making hard or painful decisions. The nurse case manager could work on the elements of discharge planning that had a greater clinical element or focus such as home care, sub-acute or long-term acute care placement.
Ultimately, the purpose in all this was to clarify and outline the roles of each professional so that the nurse case manager and the social worker’s skill sets could be optimized. This is better for the patients and families, for the organization, and for the professionals themselves.
Listed below is an example of how the work might be divided between the two disciplines:
RN Case Manager Roles:
• Patient flow or coordination and facilitation of care
• Utilization management
• Resource management
• Transitional planning
• Discharge planning — clinical focus
• Avoidable delay tracking
Social Worker Roles:
• Psychosocial counseling and interventions
• Discharge planning — psychosocial focus
By prospectively outlining the roles of each discipline, the case management needs of the patient are applied to the discipline most capable and educated to address them. The processes are clear and the roles are consistent for all patients.
Case Management Department Mistake Number Two: “Inadequate Staffing Ratios”
Once the case management department has determined its roles for the nurse case manager and the social worker, the next important area of clarification is the staffing ratio for each discipline. No department in any hospital can function adequately if the workload exceeds the staff member’s capacity. The case management department is no different than the nursing department, the hospitalists, or the physical therapists. Even residents and interns have maximum caseloads. For some reason, case management has been slow to catch on to the fact that excessive caseloads result in poor outcomes for the patients and the organization. They result in dissatisfaction for the case management staff and personnel turnover. So this is mistake number two: giving the staff more work than they can effectively accomplish in the course of a work day.
The only way to balance the workload is to balance the caseload. These two elements are interdependent, as well as the roles applied to each discipline as we discussed above. When departments switched to case management, they often retained the staffing ratios that were used when case management was utilization review. Case managers were then expected to perform additional roles and functions with the caseloads they had before. These caseloads could be as high as 50 or 60 patients. While this may seem obviously impossible, many departments plowed on, resulting in their doing only the basic essentials for each patient. The job became task-oriented and many patients were overlooked in the process.
Is Your Department a Shell of Case Management?
All a case manager can do in this situation is complete as many clinical reviews as they can and complete as much paperwork as they can. This is not case management! It is a mere shell of what case management is and can be. In order to take on additional roles and the functions associated with them, the staffing has to be adjusted accordingly. Changes in staffing patterns can emerge slowly. Many administrators asked case management to prove their value by calculating their “return on investment.” What they do not appreciate or understand was that case management is mandated by the Conditions of Participation of CMS (the Centers for Medicare & Medicaid Services). Therefore, they are a fundamental requirement of any hospital seeking reimbursement from Medicare or Medicaid. In addition, a reduction in length of stay, cost, or denials could not be achieved by the case management department alone. Every department and discipline in the hospital has a hand in these outcomes and a part to play in improving them. Constant reflection on the need for more staff sometimes works, but sometimes falls on deaf ears.
The good news is that we now have 30 years behind us as well as a much better understanding of the roles of the case manager and the appropriate staffing ratios needed to support those roles. As said before, these staffing ratios are completely dependent on the roles each discipline is performing and how the division of labor is carried out. Ultimately, the appropriate staffing ratios for your department will require a thorough understanding of your department’s model and the work to be performed. The example provided above is the gold standard in role clarification and is commonly known as the “integrated model.” Because the integrated model is best practice, we will review the staffing ratios for this model.
Staffing for Best Practice in the Integrated Model
The integrated model requires all patients to be seen by a nurse case manager. For some patients considered “high risk,” they may also be followed by a social worker. Based on the design and roles outlined for the nurse case manager and the social worker above, the tables at the bottom of the page indicate reccomended staffing ratios.
Differences in Staffing
To further clarify the differences between the RN Case Manager and the Social Worker assignments, the following descriptions can be used:
RN Case Manager: Assigned fifteen fixed beds that are consistent daily. Patients may be discharged from these beds and new admissions received into these beds over the course of a day of work.
Social Worker: Assigned up to seventeen patients based on high-risk referral criteria. These 17 patients may be located across more than one unit, depending on the size of the units. Approximately 30% of all inpatients will match with the high-risk social work referral criteria, and of these, 17 will be assigned to each social worker. In total, only 30% of all inpatients will be followed by both a social worker and a nurse case manager.
Summary
This month we have begun reviewing the top mistakes hospitals make within their case management department’s infrastructure. As discussed, the biggest mistake is to not clearly and prospectively define the roles of the RN case manager and the social worker to optimize each discipline’s skill sets. Associated with this mistake is to have inadequate patient ratios assigned to each discipline. These mistakes are related and when roles are not clearly defined, it becomes almost impossible to understand or advocate for appropriate staffing ratios. If it appears that nurses and social workers can all do the same things equally well, then the organization will likely choose to go with the professional group that will cost the organization the least amount of money. In the end, this logic is penny-wise and pound foolish. We do both disciplines a disservice when we don’t apply their skill sets adequately and don’t have each group functioning at the “top of their license!”
Next month, we will continue to discuss the top mistakes hospitals make in their acute care case management departments’ design. We will discuss the use of clerical support staff, assessments, and days of coverage.
RN Case Manager
