Avoid overload: Assign cases based on workload, model, and role functions
Many factors affect what case managers can handle
Case management directors struggle daily with how best to assign caseloads to their staff, but it’s not enough to rely on benchmarks of caseload statistics. Many other factors can affect how many patients a case manager can manage adequately, experts say.
The caseload your case managers can handle depends on the case management model your hospital uses, the role functions your case managers are expected to assume, and the case management workload, says Toni Cesta, PhD, RN, FAAN, vice president of patient flow optimization at North Shore-Long Island (NY) Jewish Health System. "It’s common sense: The more role functions you give [staff], the fewer patients they are going to be able to handle. The issue is balancing workload and caseload," she says.
The caseload, of course, refers to the number of patients a case manager manages. The workload refers to the volume of work for the case manager and is affected by a number of factors, including intensity of service needed, staffing patterns, complexity of patients, average lengths of stay, payer mix, role functions, model design, and availability of technology, Cesta adds. (For details on factors that affect workload, see chart, at bottom.)
"Inappropriate staffing ratios are probably the No. 1 reason why departments don’t function as well as they should. Effective staffing has everything to do with the type of model and the role functions of the case managers," she points out.
Case management directors need to look at staffing in a systematic way to determine how many patients each case manager can handle adequately, suggests Teresa Fugate, RN, BBA, CPHQ, CCM, manager at Pershing, Yoakley & Associates, a Knoxville, TN-based health care consulting firm. "On some floors, one case manager can manage 20 patients without any problems. On another floor where the patients have complicated needs, it may take two case managers who coordinate the care for 10 patients each," she says.
If your department has other people who handle utilization management, the case managers can handle more patients than if they are doing multiple tasks.
"If case managers are doing quality improvement review concurrently or intervening with physicians and the nursing staff to ensure that the care meets standards and indicators, they’re going to be able to see fewer patients than someone who concentrates on coordination of care," Fugate notes.
If your case managers do handle utilization review, keep in mind that commercially insured patients take more time because the case managers have to contact the insurers.
"When you look closely at how many things the case managers have to do for a patient, you can get an idea of how many patients they can handle," she says. For instance, coordinating the care of a 90-year-old patient admitted for congestive heart failure who has multiple comorbidities and no support at home may take more time than a 40-year-old patient with complications from surgery who may require just an additional authorization call to the insurance company and no discharge planning.
"A case manager may have 20 patients, but all are Medicare patients with a higher acuity than another case manager’s patients who are on the obstetrical floor. In the case of mothers with new babies, case managers may have to certify insurance, but that’s all the discharge planning they’ll have to do," Fugate says.
To determine what your staffing ratios should be, start by thoroughly evaluating the role and activities of your RN case managers and social workers to discover where their time is being spent, suggests Patrice L. Spath, BA, RHIT, health care quality specialist with Brown-Spath & Associates, based in Forest Grove, OR.
She also recommends conducting a work analysis study to determine if what they are doing is contributing to more efficient use of resources and patient flow. List the major functions now expected of case managers and ask them to keep a record of the time spent on these functions each day, Spath adds.
"This work analysis can also help the case management manager determine whether staff are performing tasks that are duplicative of work done by other people or if staff are performing activities that should be the responsibility of the nurses, unit assistants, other caregivers, or clerical support staff," she says. "The most important component of the work analysis study is asking, "Why are we doing what we are doing?"
In an ideal situation, the case manager spends the majority of his or her time actively coordinating care for patients who need intensive case management services, working with physicians and other caregivers to reduce unnecessary resource use, and evaluating the appropriateness of admission and continued stays, she says.
Use the results of the work analysis to determine the priority activities for case managers and what functions could be eliminated or assumed by other caregivers or staff members, Spath advises.
Fugate suggests CM directors take the workload analysis a step further and assign case managers according to the acuity of the patients they manage, with caseload numbers that may shift over time. "Case managers’ daily assignments should be based on the time it will take to manage the care of their continuing patients plus the new ones," she says.
Fugate recommends conducting the time studies for a two-week period. List all the case management tasks on a sheet of paper, get each case manager to tick off each task they complete, and write down the time it takes.
Calculate the average time for each task by the day, week, and period of the time study to come up with an overall average of how long it should take to complete each task.
"We’ve found that there is a natural sequence. Every time we go into a hospital, the average of each activity is around the same," Fugate explains. For instance, a new review takes an average of 20 minutes. A continued stay review takes an average of 10 to 15 minutes. Use the overall averages to determine caseload assignments on a daily basis, she suggests.
Each morning, the person who makes case management assignments should look at the demographics of new patients, determine how much time each is likely to take, and assign patients accordingly. At lunchtime, the supervisor should look to see if the time it is taking for each patient is close to the anticipated time and make adjustments if necessary.
At the end of the day, case managers should anticipate what they have to do the next day and enter it into a simple data-entry system the person making the assignments can use the next day.
"The model looks at the number of activities a case manager is responsible for and the expertise and time they each take," Fugate says.
In facilities where there are case management specialists, such as cardiology or med-surg, case management directors can use the acuity system each day to determine what staff they need in each unit. For instance, if the caseload is low in cardiology, the case manager should be knowledgeable about the care of med-surg patients and be able to fill in on the med-surg unit.
"Case managers should be cross-trained. Case managers have to be cross-trained to fill in when their colleagues are sick or on vacation, so why not on a daily basis," she says.
An acuity system can help spread the work equally, taking into account what the case managers do and the needs of their patients.
For instance, a high Medicaid population means the patients are likely to have a lot of social service needs. If your RN case managers handle that function, they should take on a smaller caseload than case managers who collaborate with social workers.
Use the information you gather from your work analysis studies to justify staffing needs to management, Cesta suggests.
Quantify the time it takes to do some of the difficult tasks and calculate how many of the tasks a case manager can do in an average day and use the data to demonstrate to administration that to complete all the case management functions in eight hours, you need a certain number of case managers for your hospital’s average daily census.
Hospital administrators who have never worked in the field may not understand that one difficult discharge plan can take a case manager as long as half a day, Cesta adds. "What many administrators don’t understand is the relationship between a good case management department and the hospital’s bottom line. They don’t understand that if they invest up front, they will get that link on the bottom line," she says.
Consider linking your staffing ratios to outcomes. If your denials are up and your length of stay is up, that may indicate there are not enough case managers to do the work.
"Showing a correlation between missing staff and outcomes is very powerful," Cesta adds.
As hospitals get a handle on their length of stay potential, staff are caring for sicker patients and sending them home sooner, which means the case management department is handling an increasingly complicated patient population and may need additional staff to accommodate their discharge planning needs, she says.
CM directors should suggest to the administration that the department conduct a pilot project that implements appropriate staffing ratios in one unit and show the outcomes for that unit, compared to one where you are short-staffed.
There are a number of simple approaches to justifying the number of staff you need to your administration. Using national ratios is the simplest, but it may not work the best because of different case management models and caseloads, Cesta points out.
There’s no right model for a hospital case management department, Spath says. "I’ve seen some hospitals change their models every two to three years trying to get it right only to return to a previously used model a few years later."
The most effective case management model is one in which the role, responsibilities, and performance expectations are defined clearly and staff are held accountable for meeting expectations, Spath says, adding "without these elements, any model will be ineffective.
"Case managers must have enough information to understand the proper contexts of their job tasks. Otherwise, they will not be able to prioritize work activities or refine job duties to meet current demands," she says.
Depending on the case management workload (see chart, at bottom), a target caseload for a case manager in an integrated case management model should be 1-to-20. In the same model with the social worker as a collaborator, the target caseload for the social worker should be 1-to-17, Cesta says.
In an integrated model, all functions are performed by a single case manager, combining all previously disconnected functions. They include clinical coordination/facilitation, utilization management, transitional planning, variance tracking, and quality management.
A rule of thumb in an integrated model is all patients should be followed by a case manager, and approximately 40% of patients should be followed by a social worker, she adds.
Other staff in an integrated model should include clerical support staff for case managers and secretarial staff for case management and social work, along with one discharge planning specialist and two audit and appeal specialists, Cesta says.
Behind-the-scenes clerical support staff can free up case managers to see more patients. She recommends one clerical staff member for every six case managers. "Models and role functions are the main factors that affect staffing because there are only so many hours in the day."
If the work analysis reveals that RN case managers and social workers are spending a lot of time on clerical duties, look for ways to allocate these tasks to other people.
Spath advises CM directors to considering hiring someone with a health information management background, rather than just adding clerical support. "This person can provide some clerical support. However, they can also help manage and analyze all the information that is coming into and going out of the department," she adds.
In the absence of additional staffing, work to get your staff more technology. Cesta suggests purchasing a case management software program, and providing personal computers, beepers, and access to fax machines and copiers for all staff members.
Using timesaving technology to contact insurers increases the time case managers have for their patients, Fugate says. Examples include Internet-based certification programs and automated voice-based communications systems.
"This technology dramatically decreases wait time, but it doesn’t do any good unless the insurance companies use it as well," she adds.
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Factors That Affect Case Managers’ Workloads
Source: Toni Cesta, PhD, RN, FAAN, Great Neck, NY. |
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