Improve the Quality of Your Case Management Department through Staffing, Part 1

By Toni Cesta, PhD, RN, FAAN

Introduction

Correct staffing of acute care case management departments has been a topic of discussion for many years now. One of the greatest challenges has been determining the best ratios of RN case managers and social workers. Early models were based on utilization alone being performed by registered nursing, and discharge planning being performed by social workers. Work was siloed and much less complex than it is today. The old staffing patterns no longer apply or function to meet the current needs of hospitals and health systems. This month, we will talk about the staffing you need to maintain a contemporary and quality outcome-producing case management department.

Roles, Models, and Staffing are Interrelated

When talking to case management colleagues, the question of staffing is the No. 1 topic of discussion. It is very difficult to discuss staffing without discussing case management roles and models. Because case management in today’s world is so complex, one size never fits all. Therefore, when determining your staffing, you must consider the following:

• the case management model you are using,
• roles and functions of the RN case manager,
• roles and functions of the social worker,
• hours of operation,
• vacancy coverage, and
• additional roles needed to support the department.

A model is a description used to help visualize something that cannot be directly seen. In the example of case management, we describe our models, or the structure in which we organize and assign our work. There are two fundamental models in use nationally. I would stress, however, that even these models may be adapted to meet the needs of your organization, its budget, and expected outcomes. The descriptions below are best practice for the models that have been tested and known to work most optimally.

The Integrated Case Management Model

In the integrated model, all roles are performed by a single RN case manager. This model integrates previously disconnected roles and functions. Included in the integrated model are all the roles listed above. The nurse case manager integrates the roles of patient flow, utilization management, and discharge planning into one role that applies to all patients assigned to her. The nurse case manager is responsible for referring any psychosocially complex patients to the social worker as they are identified.

The integrated model requires that all patients are seen by a nurse case manager. Some patients that are considered “high risk” may also be followed by a social worker.

The Collaborative Case Management Model

In this model, a third team member is added. The third member, called the Utilization/DRG Manager or Business Associate, is responsible for the business aspects of case management such as conducting clinical reviews for the purpose of transferring information to a third-party payer. They are also responsible for clinical documentation improvement. As such, the staffing ratios are different in the collaborative model. The case manager is responsible for assessing, planning, coordinating care, and outcomes management.

Differences in Staffing

To further clarify the differences between the RN case manager and the social worker assignments, the following are the descriptions of each role:

RN case manager: Assigned 15 fixed beds that are consistent daily. Patients may be discharged from these beds and new admissions received into these beds over the course of a workday.

Social worker: Assigned up to 17 patients based on high-risk referral criteria. These 17 patients may be located across more than one unit, depending on the size of the units. Approximately 30% of all inpatients will match with the high-risk social work referral criteria, and of these, 17 will be assigned to each social worker. Only 30% of all inpatients will be followed by both a social worker and a nurse case manager.

Roles and Functions of RN Case Manager

In contemporary case management departments, there are specific roles and functions to be assigned to the RN case manager. A role is defined as the set of key categories that case managers perform. Roles provide the context in which we work and can be applied differently in different clinical settings. In the collaborative model, some of these roles and functions may be assigned to a third team member, the Utilization/DRG Manager, or some such similar name. Regardless of the model selected, the following are specific roles to be included in any case management department:

• patient flow — clinical coordination/facilitation,
• utilization and resource management,
• denial management,
• variance tracking,
• clinically focused transitional and discharge planning, and
• quality management, consisting of core measures, readmissions, and adverse events.

Functions, on the other hand, are defined as the series of activities or tasks that are conducted within each role. They are the specific actions taken by a case manager in the performance of the roles. The functions are needed to complete each role. The greatest variation comes in the functions, as they can be changed and adapted to meet the needs of a clinical area such as the ED versus an inpatient unit. They also can be adapted for other areas along the continuum, such as community-based case management, home care case management, and so on.

Patient Flow

The functions associated with patient flow include the following:

• The management of all patient care processes that support a patient as they transition through the continuum of care. In the acute care setting this would include the coordination and facilitation of tests, treatments, procedures, consults, and other care interventions.
• Assessment of every patient on admission.
• Reassessment of patients daily.
• Leading and/or attending daily interdisciplinary care rounds.
• Creating a plan of care that outlines the key interventions and outcomes to be achieved each day of the inpatient stay.
• Coordination of the key interventions among and between the members of the interdisciplinary care team.
• Coordination with family and family caregiver(s).
• Identification of delays in patient care processes and intervene to correct them.

As seen in the above list, while patient flow is the role of the case manager, the functions used to complete the role are extensive and much more specific to the clinical area where the role is being carried out. This is where the variation comes into play.

Utilization and Resource Management

The same logic applies to all the roles that we have listed, so for the role of utilization and resource management, the functions applied include the following:

• Review of services to ensure:
  • medically necessary and reasonable,
  • provided in the most appropriate setting,
  • resources are being applied appropriately in the care of the patient,
  • minimal overutilization of resources,
  • minimal underutilization of resources,
  • resources include pharmaceuticals, radiology services, laboratory services, and others,
  • resources are used in a timely manner and without unnecessary delay, and
  • ensure reimbursement of services provided.

Denial Management

The third role is that of denial management. This role is applied as a front-end role by the RN case managers and also as a back-end function. The back-end role is performed by an appeals coordinator or similar title in completing audits and appeals retrospectively. Denial management is the process of monitoring and managing third-party payer reimbursement from pre-admission to post-discharge and includes:

• pre-certifications,
• billing, and
• denial management, both concurrent and retrospective.

The key functions for appeals management include:

• ensuring the clinical information available in the medical record is accurate and reflects the care rendered to the patient,
• ensuring the information is provided, when necessary, to a third-party payer in a timely manner and based on nationally established guidelines, and
• ensuring the patient is transitioned to the next level of care as quickly as possible once the patient no longer meets the clinical criteria for the current level of care.

The appeals coordinator works closely with pre-certification staff at the front end and billing staff at the back end. The coordinator also appeals denials as necessary. The sharing of these functions looks like this:

• Pre-Authorization: Finance.
• Concurrent Review: Case Management.
• Billing: Finance.
• Appeals: Case Management and Finance.

Variance Tracking

Variance tracking is another role assumed by RN case managers. Also known as avoidable delays or avoidable days, it is defined as the causes of delays in patient throughput, care delivery, or discharge. These delays may or may not result in a prolonged length of stay, but may result in delivery of care delays and/or quality of care issues.

This role includes the following functions:

• Identification of delays in throughput, service delivery, or quality of care.
• Intervention to correct the delay when possible.
• Discussion of delays on patient care rounds.
• Cataloging the delays in a database using the following categories: Internal hospital systems, systems outside of the hospital, patient issues, family issues, provider issues and delays, and payer issues.

The goals of this role include the identification of important single events; undesirable variation from established levels; and patterns or trends that vary undesirably from expected outcomes.

Clinically Focused Transitional Planning

Our next role is clinically focused transitional and discharge planning. In this role, discharge planning focuses on the movement of the patient through the acute care continuum and to the next level of care. It is defined as a collaborative, interdisciplinary process of assessment, planning, implementation, and evaluation of the patient’s healthcare needs following the current phase of illness. It involves the process of assessing the patients’ needs after they leave the acute care setting. Discharge planning ensures that the patient’s discharge is timely, appropriate, and safe, incorporating the best use of resources that the patient may need in the community.

Transitional planning, as part of this role, is the process the case manager applies to ensure appropriate resources and services are provided in the most appropriate setting or level of care. It includes the identification of the point at which the patient can move to the next level of care. For this reason, it is interrelated with the role of utilization management. Transitional planning also involves the coordination of the actual movement of the patient through the acute care continuum, and is therefore also related to the role of patient flow. While discharge planning provides a structure for the movement of the patient out of the acute care continuum, transitional planning happens within the acute care continuum.

It should be noted that in best practice case management models, the RN case manager is focused on the clinically focused elements of discharge planning while the social worker is focused on the psychosocially focused elements of discharge planning. We will review the social worker’s roles shortly. Examples of clinically focused discharge planning functions include the following:

• home care,
• home infusion,
• sub-acute rehab, medicine, and ventilator, and
• acute rehab.

The logic in dividing discharge planning this way is to use each discipline’s education and areas of expertise most optimally. By having the RN case manager focus on the clinically oriented discharge planning functions, decisions around next levels of care that require a clinical focus can be better expedited. Conversely, when the discharge plan requires more of a psychosocial focus, the social worker is better for these kinds of destinations/issues.

Roles and Functions of Social Worker

As we have discussed, in contemporary case management departments the roles of the RN case manager and social worker are clearly delineated so each discipline’s skill sets can be maximized. The RN case manager assumes the roles listed above, including portions of the discharge planning and transitional planning functions. While the RN case manager is focused on the clinical aspects of discharge planning, the social worker brings another skill set to the team in terms of knowledge of the issues associated with psychosocial support, counseling, family dynamics, family caregiver assessments, end-of-life issues, and many others. By dividing the work between the two disciplines, the patient is better assured of receiving the most optimal care available. Each discipline has different, but complementary, skill sets, and the best models capitalize on these differences. For these reasons, the following two roles are assigned to the social worker who works in a team fashion on patients that may have both clinical and psychosocial issues. In these cases, the two disciplines become a dyad and work together to achieve the best outcomes for the patient.

The two roles for the social worker are:

• psychosocial assessments and interventions, and
• psychosocially focused transitional and discharge planning.

In the first role of psychosocial assessments and interventions, the social worker performs a psychosocially focused assessment that is different from the assessment performed by the RN case manager. This assessment serves to identify any psychosocially oriented barriers to discharge or maintenance in the community. The assessment itself should include an assessment of the patient, the family or significant other, as well as other support systems. The goals of psychosocial counseling are to determine the patient’s ability to cope with their current phase of illness or chronic condition. Once identified, the social worker has the additional responsibility of creating a plan to address the issues requiring an intervention.

Psychosocially Focused Transitional Planning

In the role of psychosocially focused transitional and discharge planning, the social worker should have responsibility for those discharge destinations where these issues are most present. Examples of these include the following:

• hospice,
• long-term nursing home placement,
• acute homelessness, and
• palliative care.

Each case management department should develop its own list of social work referral criteria with these standards in mind. Depending on your own hospital’s staffing ratios of RN case managers and social workers, some of these roles and functions might need to be adjusted.

When working with RN case managers and social workers, integration is the key to discuss. Integration does not mean having both disciplines doing the same things, but rather optimizing the skill sets of each.

Quality Management

Our next, and final, role is quality management. When we discuss quality management as it relates to case management, we refer to ensuring care is rendered at or above quality standards. As case managers, we have an obligation in this regard to all members of the interdisciplinary care team. While case managers are not primarily responsible for quality in the traditional sense, they do participate in issues related to quality of care and outcomes of care.

For example, case managers may participate in the identification and documentation of adverse events, reporting these to the nurse leader of the clinical area in question. In addition, the case manager participates in the identification of patients who have been readmitted within 30 days and should document the cause of the readmission and the plan to correct it. Finally, the case manager participates in the movement of the patient toward expected outcomes of care, also known as care progression.

Summary

This month, we reviewed the roles and functions of the RN case manager and the social worker in today’s contemporary case management models. The roles and functions you choose will be dependent on the model in use and the budget at hand. There are many arguments to be made for standardizing our models, roles, and function nationally. Standardization helps case management departments obtain the staffing ratios they need to achieve the best outcomes for their patients and organization.

Next time, we will discuss new and creative ways to use the staffing within a case management department.