Assess acuity levels to set CM caseloads
Acuity drives caseloads across practice settings
Bring any group of case management executives together, and a discussion of case manager caseloads is likely to follow. How do you set reasonable caseloads that maintain the quality of your case management services? How do you justify your caseloads to administrators? Amazingly, Case Management Advisor's management panel says that regardless of practice setting, the answer to setting appropriate caseloads lies in accurate assessment of patient acuity.
"We have an acuity system for patients based on what the case manager's interventions are going to be in terms of time spent managing the case each month," says Karen Chambers Knight, RN, CCM, CDMS, director of utilization management for GuideStar Health Systems in Birmingham, AL. "Acuity level five is our highest level. Acuity level one would be a very short-term case easily handled telephonically.
"A catastrophic case with a number of transfer issues requiring case manager coordination receives a higher acuity level," she says. GuideStar has a system that allows Knight to look at each case manager's caseload by acuity level. "As each new case comes in, I assign it based on each CM's current caseload. If a case manager has a high mix of level five cases, they can't handle another. In that situation, I refer it over to another case manager - perhaps a CM with a high number of level one cases that will be gone quickly."
Marriott International in Washington, DC, also uses an acuity assessment system to set case manager caseloads for its disability manage-ment program. "We hire case managers according to population. At present, we have roughly 5,000 employees per case manager. Our case managers handle about 120 cases, all telephonically," notes Rachel Ebert, MS, FNPC, RN, COHN-S, director of occupational health services for Marriott.
As cases come in, they are assessed as MO1, MO2, or MO3. MO3 indicates a medical-only cases with no lost time. "An MO3 can actually be more complicated at times than managing someone out with lost time," Ebert says. "These cases often require coordinating with the workplace and arranging outpatient therapy. Some medical only cases only take one or two phone calls."
"In fact, an important consideration in setting caseloads is your delivery model. Do you provide strictly telephonic case management, on-site case management, or a mix of both?" asks Sandra L. Lowery, BSN, CRRN, CCM, president of Consul tants in Case Management Intervention in Francestown, NH. "Having done both, I believe that from a productivity level a successful on-site visits can cut through hours of telephonic time. However, I don't believe this has ever been proven in a research model."
Acuity levels can change
Case managers at Private Healthcare Systems in Waltham, MA, also set acuity levels based on their judgment of the time they must spend on a case.
"All of our cases are complex catastrophic cases. Acuity levels can change overnight. We revise acuity levels on a weekly basis. Our highest acuity level is an acuity two, which means that we expect the case manager to spend eight to 10 hours a month on that case," says Jean Leary, RN, BS, MS, CCM, manager for Private Healthcare Systems.
"Our system also provides a daily log of each case manager's caseload with acuity levels. As new cases come in, we use our best judgment and look at each case manager's case mix to assign cases."
Don't overlook the bottom line
HEALTHSOUTH Rehab Hospital in Concord, NH, has three case managers working in its 50-bed facility. "Our case managers work on teams. They carry between 15 and 18 cases. If a case manager works with the brain injury team, [he or she] will handle slightly fewer cases than a case manager in orthopedics. We do that based on how complicated the case is in terms of discharge needs, insurance issues, and funding for follow-up care," says Eileen Bartlett, BS, OTR-L, CCM, director of patient care services for HEALTHSOUTH.
In addition, HEALTHSOUTH has an outpatient case manager who works 24 hours a week and carries up to 30 cases.
"We have an independent company that provides follow-up assessment to measure outcomes at three months and six months after discharge. If an outcomes assessment at three months post-discharge indicates the patient needs additional therapy, the case is referred back to a case manager for follow-up," Bartlett explains.
Care managers with Senior Health Partner ship in Woburn, MA, contract with physicians in Medicare risk plans to provide care management services from the time members enroll until the time they disenroll or die, says director Denise Kress, MS, RNC, CRRN.
"We started with one care manager per 500 covered lives handling active case loads of 35 to 40 cases, but because we use only advanced practice nurses as care managers, it got very expensive," Kress explains.
To offset the cost of care management without jeopardizing the quality of its care management services, Senior Health Partnership increased its ratio to 750 covered lives per care manager and hired a clinical partner to cover its long-term care members.
"When a member transitions to a long-term care or maintenance care situation, our clinical partner takes the case," says Kress, adding that the clinical partner, an RN with home care and rehabilitation experiences, also handles "quick and dirty" cases that simply require managing a member on a pathway. Senior Health Partnership triages member risk at enrollment.
"If a member is low-risk and just needs a knee replacement, our clinical partner follows the member through that episode of illness."
However, Kress says she finds herself constantly justifying her care manager-to-member ratio.
"Physicians and administrators don't understand all the stuff that goes on behind the scenes," she says. "There are members we have literally taken care of for years that the physicians have little understanding of how we've prevented those members from utilizing services. They only see the members who end up in the hospital."
The only action that happens in health care today comes when it affects the bottom line, says Linda S. Colantino, RN, BA, CCM, assistant vice president of resource management and case management for IHS Home Care in York, PA.
"Health care is a commodity and a business, and sometimes that's sad. But, as managers, when we do things like set caseloads, we must keep that bottom line in mind."
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