When it comes to determining case management caseloads, there’s no one-size-fits-all solution. But one thing is clear — if case managers have large caseloads, they can’t perform all the duties their role requires and do them well, the experts say.
There’s no simple way to come up with an exact caseload number for every situation, says Charlotte Sortedahl, DNP, MPH, RN, CCM, assistant professor in the department of nursing at the University of Wisconsin Eau Claire, and newly elected secretary of the Commission for Case Management Certification.
“Caseloads can be different depending on the setting and the acuity of patients, as well as the duties of the case manager,” Sortedahl says.
“The days of case managers having caseloads of 20 to 30 patients are over from the perspective of being able to manage efficiently and effectively. Case managers have too many responsibilities to handle a big caseload,” says BK Kizziar, RN-BC, CCM, owner of BK & Associates, a Southlake, TX, case management consulting firm.
How many patients case managers can manage and do their job well boils down to the responsibilities of the case manager in a particular environment, Kizziar says.
For instance, if case managers perform utilization review, care coordination, managing the cost of care and the progression of care during the hospital stay and through the post-acute transition period, caseloads have to be small. If they aren’t responsible for utilization review and can concentrate on the hospital stay and post-acute transitions, their caseloads can be somewhat larger, she says.
Toni Cesta, RN, PhD, FAAN, partner and consultant in Dallas-based Case Management Concepts, recommends a caseload of one RN case manager to 15 patients on a typical medical-surgical unit that has case management software and support staff who free case managers from clerical duties.
“When case management departments have information technology support and clerical staff, it frees up the professional staff to manage their patients at the top of their license,” she says.
She recommends assigning different tasks to social workers and RN case managers. “The two disciplines have different areas of expertise and you’re not optimizing the skill sets of each if they have the same job description,” she says.
“Psychosocial issues often get lost for a patient in crisis. If we don’t have social workers operating at the top of their licenses, we wind up getting patients with social problems who keep coming back to the hospital,” she adds.
Hospitals should consider moving to a case management model that separates utilization management from discharge planning and care coordination, says Karen Zander, RN, MS, CMAC, FAAN, president and co-owner of the Center for Case Management.
“Whether this is the right move depends on a lot of things and varies from hospital to hospital. It’s important to look at payer mix before changing models,” she adds.
The case management model of the future may merge the functions of utilization management and clinical documentation improvement, Zander says.
“We can see a time when those two functions are merged. At the very least, utilization review people need to know something about clinical documentation improvement and need to know some general rules about improving reimbursement,” she says.
Case management models are likely to change when bundled payments become widespread, Zander says.
Case management in the future is going to require a combination of unit-based and service-based staff, Zander says. “Not every patient in the hospital is going to be covered by a bundled payment arrangement. Hospitals will need some case managers zeroing in on the bundled diagnoses to manage patients covered by the risk contracts. But others will have to coordinate care and plan the discharges for patients who are not part of a bundled payment arrangement,” she says.
A new role is likely to be a transition case manager, who follows patients through the hospital stay and for all 90 days after discharge, Zander says.
“This makes the most sense. It would eliminate information getting lost during handoffs and patients having to get used to a new case manager when they move to another level of care. Patients often keep the same doctor for the 90 days post-discharge, particularly if it’s a specialist, so they might as well keep the same case manager,” she says.
Having case managers who follow patients throughout the duration of the bundled payment period will reduce the caseload for the unit-based case managers who can coordinate care for patients for whom the hospital is not at risk, she adds.
Whatever model you choose, have a structure in place so you can evaluate what is working and what can be improved, Sortedahl suggests.
And whatever model you have, locate your case managers on the unit, not stuck away in a remote office, Kizziar says.
“How effective case managers are still comes down to communicating, not only with the patient but with the entire multidisciplinary team. Case managers need to make rounds with the doctors, talk to the family, and find out what is going on when patients are unable or unwilling to provide the information case managers need to develop a comprehensive transition plan,” Kizziar says.
Once case management directors get approval to hire additional staff, it may be a challenge to find them and get them up to speed, according to Cesta.
“Case managers and case management directors are starting to retire and there’s no one to fill their shoes. There is a huge need for case managers across the continuum, but it’s the rare staff nurse who says they want to be a case manager without someone tapping them on the shoulder,” she says.
And you can’t just move nurses into a case management position and expect them to function effectively from Day 1, Cesta adds.
“Case management requires a whole new body of knowledge and an added set of skills for bedside nurses,” she points out.
New staff need to have a clear understanding of what case management is, Lattimer says. “Case management is a professional delivery of services through standards of practice,” she adds.
In some hospitals, utilization management nurses who are accustomed to dealing with length of stay and criteria are being moved into case management with little training, Lattimer says. “Utilization management is not a synonym for case management. They are two different protocols and hospitals need to provide training when nurses take on a new position,” she adds.
Healthcare is getting more complicated by the day and case managers are being expected to understand all the changes, Kizziar says.
“Nursing school doesn’t teach the business of healthcare. Most nurses and social workers in the hospital setting know nothing about the business part of the hospital. If they become case managers, nurses don’t automatically know about the financial aspects of the job. This may limit the effectiveness of the treatment plan,” she says.
Hospitals have orientation for new employees, but most of it tends to focus on policies and procedures and using the hospital’s information system, Lattimer says.
Lattimer recommends that case management directors refer nurses who are thinking of becoming case managers or those who have just been added to the department to the CMSA Career and Knowledge Pathways online educational program. (More information can be found at www.cmsa.org/ckp.)
“Case managers couldn’t do their job without a nursing background, but they have to let go of that nursing mentality to be a successful case manager. Healthcare providers never consider the financial side, but case managers have to learn it and embrace it,” Kizziar says.
For instance, if a physician orders services for a patient, nurses never think about how the hospital is affected if the treatment costs the hospital $1,500 and the reimbursement is only $1,100, Kizziar says.
“This kind of awareness has to be in the forefront for case managers. They have to make sure that the patients get what they need when they need, but it can be difficult because a case manager may know that a patient would benefit from something they can’t afford to pay for out of pocket and that their insurance doesn’t cover,” she says.
When it comes to determining case management caseloads, there’s no one-size-fits-all solution. But one thing is clear — if case managers have large caseloads, they can’t perform all the duties their role requires and do them well, the experts say.
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