Want more staff? It’s all about the data
Do your homework before making request
Before case management directors can make the case for more staff, the hospital leadership has to identify case management as a valued program, and in order to be considered valuable, the case management department has to develop a structure, identify the processes it performs, and be able to speak to its outcomes, says Denise Majeski, MSN, RN ACM NE-BC, interim chief nurse executive at Northwestern-Lake Forest Hospital in Lake Forest, IL.
"Case management departments must have clear policies and procedures, including the assignment of staff and a clear orientation process. They should have a way to measure productivity and have staff performance dashboards that align with organization statistics," she says.
Begin by defining your mission and goals, making sure they are aligned with the mission and goals of the organization. Map out the responsibilities of the department, roles of the staff, detailed job descriptions, and department policies and procedures, she says.
"You have to start with a model. Develop a model that includes each function of case management and show that if you have the right staffing mix, the goals of the model can be achieved," she says.
Start by making sure the right roles and functions are assigned to case managers and nurses and that they don’t do work outside their scope of knowledge, suggests Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, and partner and consultant in Dallas-based Case Management Concepts.
Look at the resources you have and make sure they are being deployed appropriately and to the skill set and level of expertise of the people doing the job. Do a gap analysis to determine where you need help. List the activities that case managers do on a day-to-day basis and determine if they are something only a case manager can do or could other staff assist with them, she suggests. Tabulate the time involved and use the information to determine if you have the appropriate staff ratios to cover all the activities, Cesta says.
No magic formulas
There is no magic formula for determining case management caseloads, adds BK Kizziar, RNC, CCM, CLCP, a case management consultant based in Southlake, TX. They are based strictly on the responsibility of the case management staff and how the responsibilities are distributed and may differ from hospital to hospital and unit to unit, Kizziar points out.
To determine your optimal caseloads, make a comprehensive list of the responsibilities of case managers and how long it takes in a typical day to meet each element of responsibility, Kizziar says. Determine how many tasks are done in a day and you can determine how many case managers you need to do those tasks.
Look at what the case managers’ responsibilities are and ensure that they have the tools to do them. If they are still putting in long hours or not getting the job done, they may be doing tasks that are not case management-related, Kizziar says.
"Your request to management has to be borne out in the data. Anecdotal stories of staff staying late and not getting the work done just don’t fly," Kizziar says.
Before you approach management about adding positions, develop a business plan, using a format that outlines what is needed and why it’s needed using objective data, Cesta says. Data is essential. Don’t approach the subject from an emotional viewpoint. Chief financial officers relate to data, she adds.
Define the business opportunity, and plan the work effort. Have alternatives in mind when you approach the administration.
For instance, if you want a specialty position to handle complex discharge planning, tally the average number of complex patients who need a significant amount of discharge planning and the average time each case takes. Show how the complex cases slow down the regular case management work by X number of days to demonstrate the need for the position.
Kizziar gives another example: If your initial and concurrent utilization reviews take an average of 12 minutes, come up with the number of utilization reviews the average case manager does in a day. Use that information to show that having dedicated staff doing utilization review can free up case managers to meet with families and prepare them for discharge or collaborating with the nurses to make sure everything is being done to move the patient through the continuum, such as removing the catheter or getting the patient out of bed and ambulating, she says.
To justify other staff, look at how many payer denials your hospital receives that are due to lack of clinical data or how many 30-day readmissions you experience. Tie a dollar amount to the lost revenue and compare it to the cost of redesigning the program or adding staff.
Whenever possible, tie your requests to a dollar figure, suggests Jenny Prescia, MSN, RN, ACM, CCDS, interim director of case management for Northwestern-Lake Forest Hospital in Lake Forest, IL.
"Case managers affect quality through the readmission rate, denials, transitions of care, and care coordination, but quality needs to be tied to dollars. Otherwise, it’s too easy to say that salaries are too high and cut the department," Prescia says.
For instance, in addition to showing management your denial overturn rate, include a dollar figure on how much you recouped. "This will make an impact in case the leadership is trying to cut costs and sees your department salaries as low-hanging fruit," Prescia says.
When the case management team at Northwestern-Lake Forest wanted to expand to the outpatient side, the team used its dashboard of metrics that showed what case managers do on the inpatient side, how their efforts affect revenue and reduce financial risk, and shared it with the organizational leadership as well the physician leadership.
The department was able to add an outpatient orders management unit staffed by RN case managers who are assisted by highly trained clerks called case order management specialists, Prescia says. The unit reviews every outpatient order for medical necessity and order correctness, performs pre-billing denials management, works closely with physicians, and handles Advance Beneficiary Notices. The outpatient orders management team also covers two outpatient infusion centers and gets preauthorizations for every infusion and reviews every case for medical necessity. Last year, the team achieved an 88% turnover rate for denials.
The outpatient team collaborates with the inpatient case managers on transitions of care and discharge planning. "They work together, looking for the least costly discharge plan. For instance, if patients need infusion services after discharge, they may be able to arrange for the patients to come to the outpatient infusion center rather than having a home health nurse do the infusion at home," she says.
