Designing case management: The top 10 issues to consider
Experts share advice, guidance on designing/redesigning your program
With a challenge the size and scope of designing or redesigning a case management program, the first question, invariably, is "Where does one begin?" There are so many issues to consider that it can be easy to overlook important details if the project isn’t approached in a systematic way.
Here, Toni Cesta, PhD, RN, FAAN, director of case management at Saint Vincents Hospital in New York City, Anne Llewellyn, RN.C, BHSA, CCM, CRRN, CEAC, co-founder of Professional Resources in Management Education in Miramar, FL, and Julia Rieve, RN, BSHCM, CCM, CDAF CPHQ, FNAHQ, president of CQI-Healthcare Management Services Company in San Diego team up to provide a framework for approaching that process in the form of a top 10 list. The principles are equally useful for evaluating and making changes to a case management program already in place.
Case managers first should initiate a complete assessment of all utilization and quality assurance roles, functions, and policies, Rieve says. Often, components of case management exist throughout the system and must be assessed in order to understand structure and function, she says. Case managers should find out if any indicators, outcomes, or benchmarks exist for case management. If not, they should establish basic indicators and document before initiating change to identify a baseline. At that point, Rieve says, case managers should discuss their findings with key administrative staff such as the chief financial officer (CFO) to determine their definition of goals. The most important question to ask is, "How will the case management department be measured for success?"
Case management departments also must determine the department’s goals, document those in writing to all significant staff, and develop a written plan to achieve those goals in an established timeframe. The next step is to ensure that staff selected for case management positions have training in case management specific to the organization as well as health care finance and quality management so that identification and tabulation of variances and outcomes are a part of the process.
"Be sure to provide information and education to physicians and other providers of care to keep them informed of changes and also to encourage collaboration and partnerships," Rieve asserts. "No case manager or case management department can provide services alone. Education and collaboration is the best approach."
Here are the top 10 considerations outlined by the three experts:
1. Define your goal for the case management program and obtain buy-in from administration. In order to have a successful program, case managers must define clear goals for the program and secure corporate buy-in, Llewellyn says. Case managers should meet with key people to understand the needs of the organization and then design a program that will address those needs. Resources to aid that process are available. For example, the Case Management Society of American has developed Standards of Practice for Case Management Professionals, Llewellyn notes. "These standards can be used as a key resource for those developing new and updating existing programs," she says.
2. Define role functions and corresponding job descriptions for case managers and social workers. Cesta says case managers must clearly and prospectively define the role functions to be performed by each discipline. "You must document these functions as part of the department’s policy and procedure manual and optimize the unique skill sets of each discipline," she says.
According to Llewellyn, collaboration among various disciplines is important to the success of the program. "You will have some duplication, but by optimizing the unique skill sets of each discipline and the benefits of each, you will build a solid team," she says.
3. Identify an appropriate caseload. "There is no magic formula for determining caseload," Llewellyn says. "It will depend on your individual organization and how you structure the department." The goal is to allow case managers adequate time to interact with the patient, she says. "If you are truly going to have a case management department, then interaction with patients, families, and other health care team members is essential. If not, you are doing utilization management, not case management."
When attempting to balance the caseload, Cesta says, case management departments must consider acuity, length of stay, and specific role functions to be performed. She says they also should consider coverage for weekends, holidays, and vacation and sick days for case managers.
4. Determine the model design. The next step is to determine the model design. While unit-based is the most commonly used design, other models include product line, physician aligned, across the continuum, and by payer, Cesta says.
According to Rieve, case managers should design process flowcharts and continue refining them until the process appears to be optimal, then determine the staff needed to perform these tasks.
"Whatever model you decide to use, make sure you have buy-in from the entire team and all understand the role of the case manager," adds Llewellyn. When designing the model, case managers must make sure to include all of the team members in the process so that everyone is clear on his or her role and has realistic expectations. In addition, they must make sure that each case manager knows his or her role and is able to show outcomes to support that role.
5. Develop an appropriate budget. When developing the budget, Cesta says, case managers must first consider the number of full-time employees required as well as necessities such as equipment (for example, computers, fax and copy machines, Palm Pilots, and mobile telephones) and clerical support staff. Other important considerations include hours of operation and what days of the week coverage will be required, she says.
The budget also should include continuing education opportunities so staff can stay clinically up to date, Llewellyn says.
Case managers should develop a relationship with the CFO, Rieve stresses. "Budgetarial outcomes often are based on a very complex health care financing model." It also is important to develop a case management operational business plan that includes role, structure, function, process, indicators, outcomes, goals, and budgetary needs and to submit that to administration for approval, she says. Finally, case managers should include shared time and expertise from information systems, the CFO, and other key administrative staff, she explains. Case managers should be sure to participate in the organization contracts with payers and providers when possible to provide accomplishable goals.
6. Select outcome indicators for the department. Selecting outcome indicators for the department is another critical step, Cesta says. It is important for case managers to determine how they will measure the department’s success before they begin and to collect pre-implementation data such as length of stay, patient satisfaction, turn-around time for tests, consults, procedures, denials, and cost per case.
According to Llewellyn, this information should be made available to all key stakeholders, especially the case managers. "Many organizations collect outcomes and don’t share the information," she says. Llewellyn says case managers should have a role in designing outcomes indicators so that they have buy-in for the process. Quality-of-life indicators also should be considered when talking about outcomes, she adds.
"Soft outcomes" should not be overlooked either, Llewellyn says. Patient, family, and provider satisfaction, the education of patients, family, and staff, advocating for the opportunity of the patient and family to assert their wishes, and assisting health care providers in communicating with patients effectively are all examples of "soft outcomes." Using patient surveys after discharge to gauge their interaction with case managers is helpful in collecting outcomes, she adds.
7. Design a variance collection process. According to Cesta, case managers must select variance indicators early in the process of establishing a case management program. Examples of indicators that are typically used are system, patient, family, and practitioner. "Automate the process if possible." Variance monitors are used as a way of identifying any issues that affect quality, cost, or length of stay, Cesta says. "A variance occurs when what is supposed to happen does not take place. It is defined as a deviation from a standard or omission of an activity or a step from a predetermined plan, norm, goal, or threshold." Variance data collection is important because it provides the basis for improvements in patient care activities, processes, outcomes, and quality, she adds.
As part of the design process, case managers should have a way to report outcomes and determine how variances will be used as part of the quality improvement process, Llewellyn says. Involving risk management in this process is important regarding documentation of variances, she adds.
8. Operationalize a case management software product. If the budget permits, Cesta says, case management departments should choose a case management software product that meets the department’s needs. "Be sure the program you select can support the role functions you identified in the goals for the case management program," she adds.
A case management model should be manually operational for at least a year to delineate a work-flow process before considering computerization, Rieve says. Most quality software companies will ask what the manual workflow process is in order to understand what automation may best support the case managers and the case management department, she adds. "Be sure to work with the organization’s information services department regarding computability before selecting any software product."
9. Select a case management clinical guideline format. When selecting a case management clinical guideline format, Cesta advises case managers to select from among the many options available in case management tools and to consider their audience and their goals for using the tool. Options include clinical practice guidelines, multidisciplinary action plans, clinical pathways, algorithms, patient pathways, and standing order sets.
To ensure use, Llewellyn says case managers should make sure that all team members are part of the group that selects the format. "This will ensure buy-in and increase use," she explains. It is also important to measure outcomes and the effectiveness of the tool, she maintains. "Having a trial period, measuring efficiency and effectiveness, and making needed refinements help people to see that the process is working," Llewellyn says.
Rieve argues that case managers should select no more than two clinical guidelines formats to work on each year.
10. Educate the staff and the organization. Case managers must provide a comprehensive orientation for all staff in the case management department, Cesta says, and provide additional, less- intensive education for the rest of the organization. "This is an essential process that often is not done," she warns. In addition to education at the start of the program, case managers should make sure that education is an ongoing event in order to keep everyone clinically proficient, Cesta says.
"Concurrent information is very important to the continuous improvement process of case management," Rieve adds.
Finally, Cesta and Llewellyn say case managers must be prepared to reevaluate outcomes, make improvements, and implement changes to the design of the program. In short, keep moving forward and be proactive.
[For more information, contact:
- Toni Cesta, PhD, RN, FAAN, Director of Case Management, Saint Vincents Hospital and Medical Center, New York City. E-mail: [email protected].
- Anne Llewellyn, RN.C, BHSA, CCM, CRRN, CEAC, Professional Resources in Management Education, Miramar, FL. Telephone: (954) 436-6300, ext. 30. E-mail: [email protected].
- Julia Rieve, RN, BSHCM, CCM, CDAF CPHQ, FNAHQ, President, CQI-Healthcare Management Services Co., San Diego. Telephone: (619) 226-4141. E-mail: [email protected].]
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