By Jeni Miller
In most clinical disciplines, a standardized caseload is the norm and has existed for quite some time. However, that is not the norm in case management. There has not yet been a standard, agreed-upon caseload, and that often has meant case managers are spread thin with too many patients or excess work.
“There’s a lack of understanding of the contemporary roles that case managers and social workers can take on, and the correct ratios needed for those enhanced roles,” says Toni Cesta, PhD, RN, FAAN, partner and consultant with Case Management Concepts. “There’s also a reticence for senior leaders to put resources behind these models of case management.”
There are serious benefits to standardizing the caseload, and few downsides, other than budgetary concerns. “If we standardize the caseload, everyone knows exactly what work to do each day, and we’re working with ratios that are tested and reliable,” Cesta explains. “If case management departments were staffed in these ways, we would see far better outcomes for hospitals, including shortening the length of stay, reducing denials, lowering the readmission rate, improving patient flow, and myriad positive outcomes.”
When the hospital is not adequately staffed, it creates a gap in vacancy coverage. If the expected ratio is 1:15, and there is not enough staff — if someone is out then case managers will immediately be well over the ideal ratios, preventing them from completing work.
“We need float positions to fill vacancies, especially for maternity leave, sick days, or jury duty commitments,” Cesta notes. “This way, someone without a 15-bed caseload can cover that position so that another case manager is not just doubling up on assignments, which makes it challenging to get all the work done. Other hospital departments have these floaters, but so far, not case management.”
Since a department should adequately cover patient cases at least six days a week, Cesta recommends a formula that indicates how many additional float positions would be needed.
“You never want to have four people out and no coverage,” Cesta explains. “It’s good to have float positions based on the maximum number of people who may be out on any given day. Using a standardized formula allows the director to determine the department’s needs prospectively. It’s seldom that someone is not on vacation at a given time, or taking a personal day, [or something else]. Vacancy coverage is so needed if you want to keep everything running smoothly.”
Case managers should strive for fixed beds that are consistent each day. This means when patients are discharged from these beds and new admissions are received, they would then be part of that case manager’s caseload.
Focusing on Staffing Models First
Ensuring an appropriately standardized caseload also depends on employing the right staffing model. There are essentially two models: the integrated model, also called the “dyad” model; and the collaborative, or “triad,” model.
“The integrated model is designed so that all patients are followed by an RN case manager,” Cesta explains. “The RN case manager completes an admission assessment that includes criteria for referral to a social worker or home care as needed.”
Below is a list Cesta says can help case management departments determine how to adjust that standard based on the case management model:
Integrated Model
Unit Type and Case Manager-to-Bed Ratios:
- Surgical, including subspecialties like Neurosurgery and Orthopedics: 1:15;
- Medical, including subspecialties like Oncology and Cardiology: 1:15;
- Intensive care: 1:20;
- Step-down (Intermediate): 1:15;
- OB/GYN: 1:20;
- Neurology: 1:15;
- Pediatric: 1:20;
- Observation: 1:12;
- Acute rehab: 1:15.
Most notably, the observation caseload’s ratio of case managers to beds/cases is smaller, since CMS pays based on a 24-hour or shorter observation period. This incentivizes case managers to move the patient through observation in 24 hours or less.
Then, patients are referred to the social worker based on the high-risk criteria or referred to home care, if appropriate. Case managers follow patients from admission to discharge, and the social worker completes a psychosocial assessment and follows the case as needed. They may close the case at any time based on professional judgment.
Around 30% of inpatients will match high-risk social work referral criteria, Cesta notes. Of those, 17 will be assigned to a social worker. Depending on the size of the units, these patients may be located across more than one unit, Cesta says. “In total, only 30% of all inpatients will be followed by both a social worker and a nurse case manager,” she adds.
High-risk social work criteria include:
- Adjustment to illness or difficulty coping;
- Major illness causing lifestyle change;
- Behavior management problems;
- New or poor prognosis;
- End stage of illness;
- Family concerns and/or conflicts;
- Cultural and/or language issues;
- Inadequate social and/or financial supports;
- Nonadherence issues;
- Ethical concerns;
- Abuse and/or neglect of elder, adult, child;
- Multisystem trauma;
- Psychiatric and/or substance abuse issues affecting current hospitalization or discharge destination;
- Homelessness affecting current hospitalization or request for housing;
- Patient/family considering long-term care placement, hospice, assisted living, or adult home.
Case management leaders should work to assign the same 15 to 17 beds to case managers each day, rather than assigning them different patients. In some cases, Cesta witnessed case management leaders taking an hour and a half or more each morning to assign patients to case managers, with no continuity from the day before. This is a suboptimal approach that should be streamlined.
The collaborative model functions similarly, but with three people — the case manager, the social worker, and a third position that is like a business associate.
“The biggest difference between the collaborative model and the integrated model is with the third position,” Cesta notes. “It covers the financial side of what we do in case management. Instead of the integration of utilization management into the case manager role, this third staff member focuses on utilization management and documentation, freeing up case managers to focus on discharge planning and care coordination. In this model, the RN is performing admission assessments, risk screening, coordination of care, patient flow, resource management, and is looking to be sure the patient is getting the interventions they need — and no more and no less than they need.”
Choosing either of these models will help reduce the workload for case managers, and the staffing ratios can even change a bit depending on which model is used. For example, the case manager might be able to take on up to 23 cases (instead of 15) if there is someone else handling utilization management. However, the social worker role is best carried out with 17 patients, with 30% of all patients active/open cases. In the collaborative model, the business specialist/utilization review nurse should aim for 20-40 cases.
When working to choose the staffing model that best fits a particular hospital or unit, it may help to consider the advantages of each one.
The integrated staffing model allows data to be collected once for multiple purposes, allows the case manager to directly communicate with third-party payors and vendors, as well as physicians and staff, and may be more cost-effective because it usually requires less staffing.
The collaborative model offers the case manager more time to focus on clinical functions and accurate documentation, can alleviate worker frustration and competing priorities, and create holistic jobs that optimize the skills and talents of different disciplines. If this model is chosen, it is best for the business associate/utilization management role to be in house to round with the other team members, rather than off site in an office.
“A demonstration unit is a good place to start if you don’t have buy-in to fully re-engineer the department with a standardized caseload and appropriate staffing model,” Cesta says. “You should first pick a nursing unit that would be a good place to ‘host’ the demonstration, usually a hospitalist unit or medical unit. Once you do it, even if leadership is initially resistant, they will never want to go back. They’ll see the results and will want to carry it into the other units as well.”
When transitioning to one of these models, it is important to obtain permission for the demonstration and design a plan with best practices in mind. After rolling it out, continue for a month or longer as it takes a while for everyone — including case management staff — to get up to speed and become a well-oiled machine. Three months is ideal for the best outcomes.
“There is so much opportunity to be had in a well-designed department,” Cesta notes. “If staffing ratios are off, departments will just not be as successful, but when you take the time to develop consistency and coverage, the case manager and social worker have ample time to support their patients and the patients’ families.”
In most clinical disciplines, a standardized caseload is the norm and has existed for quite some time. However, that is not the norm in case management. There has not yet been a standard, agreed-upon caseload, and that often has meant case managers are spread thin with too many patients or excess work.
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