Show value of your case management department to justify adding staff
Case managers often asked to do more than they can handle
Most case management departments need more staff to adequately perform their duties — but how do you justify it to a hospital administration that is pinching pennies just to stay afloat in today's tightening health care marketplace?
Case managers have to make the business case for hiring more staff; that means tracking what you do every day, determining the impact that case management has on financial health of the hospital, and creating reports to show to administration, says Toni Cesta, RN, PhD, FAAN, vice president, patient flow optimization for the North Shore-Long Island Jewish Health System and health care consultant and partner in Case Management Concepts LLC.
Case managers often are called on to take on additional tasks "because they're in the charts already," but it can get to the point that case managers are asked to do much more than they can handle in a day, she says
"The more functions you give a hospital case manager, the fewer patients she can manage. Taking on more and more and not being able to adequately complete the work taken on is not positive for the department, or the organization," Cesta says.
Making the case for more FTEs
"Data have helped us demonstrate to the hospital administration what we are producing for our FTEs. Tracking a wide range of data is critical when it comes to explaining how case management contributes to the hospital's overall objectives," adds Judy Milne, RN, MSN, CPHQ, director of integrated case management and quality improvement at Sarasota (FL) Memorial Hospital.
Having strong data to show the value of case management has helped Milne keep her staffing stable for the past five years.
However, she adds, "when times get really tough, it's not going to matter. If the whole organization is struggling, we will have to reduce staff regardless of our data."
The case management department at DCH Health System in Tuscaloosa, AL, recently added four 0.7 FTEs to the staff at its two largest hospitals, says Brian Pisarsky, RN, BS, ACM, CPUR, director of case management services at DCH Regional Medical Center and DCH Northport Medical Center
"We try to find a way to measure everything we do to show the value of interventions by the case managers," says Pisarsky, who provides administration with monthly reports that include dollar amounts for case management interventions.
When Southern Ocean County Hospital in Manahawkin, NJ, developed its case management program, Marilyn Butler, RN, MSN, CCM, director of case management, was able to supply data that helped her to get her administration to agree to keep caseloads at a maximum of 15-16 patients.
"At our hospitals, case managers see 100% of the patients, and they review every patient every day, including Medicare patients. In addition to handling the utilization review piece, they are involved in discharge planning activities such as setting up post-acute services; they track measures and work with the quality team on quality issues," she says.
Other departments have cut staff in recent months, but so far Butler has kept all her case managers.
Where documentation improvement fits
Now that the Centers for Medicare & Medicaid Services has implemented the new severity-adjusted MS-DRG system, hospitals must have a documentation improvement program, but it's not something that can be added to a case manager's daily workload, Cesta says.
"The severity levels in the MS-DRG system are significantly different in terms of dollar reimbursement, but the volume of work is untenable for case managers to take on," she says.
Case management directors may be able to justify the additional FTEs for a documentation improvement project by demonstrating the increase in the case-mix index.
"With the severity-adjusted DRGs, hospitals can't afford not to do it. When a case gets coded into a lesser DRG, it can mean a significant reduction in dollars," Cesta explains.
When you approach your hospital's administration to make a pitch for more staff, keep in mind that the administration may not completely understand what case managers do, Cesta cautions.
You may need to explain the roles of your department before you make the case for more staff.
Track data to make case
If you don't think you have enough resources to do the job your department is charged with, collect data and use those to justify more staff, Milne advises.
Take your list of case management functions and determine the time frames in which each role and set of functions must be performed. For instance, reviews may have to be completed by noon each day or discharges must be expedited for a 10 a.m. discharge time.
Then perform a time and motion study to measure case management productivity. Start by determining the average number of reviews done each day by each staff member. Then determine the average length of time it takes to complete each review, Cesta suggests.
For instance, before approaching administration on a final case management model at Southern Ocean County Hospital, Butler conducted a pilot on the telemetry unit in which the case managers tracked the time it took to complete each task they did every day.
Butler created a sheet on which case managers entered the patient name or medical record number and wrote down the time they started a review and the time they finished it. They tracked the time it took to get authorization from a managed care company and the time it took to order equipment or set up home care or fax information to the nursing home.
"We tried to capture every minute they were involved in something. Any case manager can tell you that one case could take you all day if it's complicated and the family is involved. We wanted to get down on paper how hard our case managers work and how long it takes for them to do their jobs well," she explains.
Butler suggests having your case manager time everything he or she does every day for at least a week. "Every day is different. You need to track case management time for at least a week and come up with an average," she says.
You may be able to use your data to show the relationship between the shortage of staff and the bottom line of the organization, Cesta points out
"If the data demonstrate the negative quality or financial impact of the department's inability to successfully complete all it has to do, case management directors can use the information to make the case for more staff," Cesta says.
For instance, track the amount of time it takes for case managers to review a patient admission and compare it to the number of admissions and the number of case managers on staff, Milne suggests.
You may be able to demonstrate that, with the staff you have, you can review only a certain percentage of admissions.
Then determine what percentage of the cases that were reviewed were inappropriate admissions that the case managers were able to avoid.
How staffing could affect admissions
Use those data to show how many inappropriate admissions the hospital could avoid if you had enough case managers to review every admission.
"It is critical to keep an ongoing case management report card that demonstrates which areas of the organization are impacted by case management roles and functions and provides a barometer of how the department and organization are doing," Cesta says.
Select quality and financial metrics to track since case management affects both, she says.
Examples of financial metrics may be denials and appeals, excess and avoidable days, inappropriate admissions, observation hours, and short stays. Whenever possible, include the dollar impact associated with the case management interventions, Cesta says.
Include cost avoidance examples in your report, she suggests. For example, determine the number of inappropriate admissions you diverted from the ED. Follow the cases you affected for expedited discharges. Show how many avoidable days were prevented through your case management interventions.
At Southern Ocean County Hospital, the case management department keeps track of avoidable days and denials and uses hospital information system data to put a dollar amount to how much they have saved.
Using the data Butler compiles, the vice president of medical affairs gives individual physicians a report card with details of how much they cost the hospital by denials and avoidable days.
The case managers track any time they can expedite a discharge that is being held up pending a test or procedure or get the physician to agree that the test can be done on an outpatient basis.
"We try to save the hospital as much money as possible, but they have to know that we are saving money. That's why these reports are so important; you have to toot your own horn," Butler says.
Milne tracks case management outcomes including length of stay, denials, observation vs. inpatient status and produces a PowerPoint slide presentation that she reviews with her staff on a quarterly basis.
She tracks a wide range of data that include case management process data, avoidable days, denials and those the financial case managers successfully appeal, and statewide statistics that relate to case management.
Milne shares the data in the hospital's weekly patient flow meeting attended by the CEO, the chief nursing officer, nursing, and ancillary department representatives.
"I use every opportunity to share our data at random meetings when length of stay or denials are discussed. I want to make sure that people are aware of our key statistics and are aware that case management is driving them," she reports.
[For more information, contact: Marilyn Butler, director of case management, Southern Ocean County Hospital, Manahawkin, NJ. E-mail: [email protected]; Toni Cesta, RN, PhD, FAAN, vice president, patient flow optimization, North Shore-Long Island Jewish Health System. E-mail: [email protected]; Judy Milne, director of integrated case management and quality improvement, at Sarasota (FL) Memorial Hospital. E-mail: [email protected].]
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