Job responsibilities should determine case managers’ caseload
Job responsibilities should determine case managers’ caseload
Experts say it’s difficult to apply one answer to all
While case management directors continue to search for the most appropriate caseload for the case managers in their departments, experts say there’s no magic number and no one-size-fits-all solution. Rather, the number of patients a case manager can handle effectively depends largely on the manager’s overall responsibilities and the hospital’s case management model.
Hospital industry experts recognize several case management models, including physician-based, unit-based, specialty-based, and community-based. But because case management and its models are defined differently, it’s useless to apply a textbook appropriate case manager-patient ratio without first having details of individual jobs.
"Benchmarks are helpful in a general sense in that they give you a place to start, but regardless of the hospital, you have to look at everything, from the process to the staff to the organization," says Julia Rieve, president of CQI Healthcare Management Consulting in San Diego.
Sue Erickson, RN, MPH, assistant hospital director at Vanderbilt University Medical Center in Nashville, TN, says among the first steps in implementing a model is to consider the population volume and the complexity and nuances of that population. "Are they complex high-acuity patients, a heterogeneous population, [or] are they a single point of care? There are a lot of different factors that go into the decision," Erickson says.
Beyond that, it is probably safe to say that all case managers perform duties of patient assessment, coordination of care, discharge planning, and resource utilization, she adds. Most case managers also are involved in outcomes evaluation to some level of degree and success, but as Erickson says, they should be more involved in that aspect.
For Rieve, redesigning a hospital begins by evaluating the duties of the full-time case management and support staffs and identifying the model facility managers are considering. It is not uncommon to find case managers saddled with clerical tasks for which they are overqualified and overpaid. "I want to see if there are duties that can be redirected to support staff so that case managers can put more focus on clinical responsibilities and possibly increase the number of patients that can be handled."
She adds, "About 80% of the time, I find case managers who are responsible for tasks beyond clinical duties."
Although that phenomenon is common, it’s not to say that a significant number of case managers are spending excessive time typing forms and filing papers. Rather, they may have time-consuming duties, including utilization management.
At Vanderbilt, nurse case managers operate under the triad model, in which they work in partnership with social workers and the utilization management team. "It is the UM/DRG specialist who is doing routine calling and taking care of the insurance part," Erickson said. "Because they are the DRG managers, they spend a lot of time working with physicians making sure the physician documentation matches the services provided to the patient." The utilization management team then works with the physicians around the issues of documentation, coding, and admission status. This frees up time for case managers to be more clinically based.
How many patients can they handle?
Rieve says the patient load should decrease if case managers are responsible for tasks beyond clinical care, including utilization review, discharge planning, or DRG optimization. In an acute care facility where the average length of stay is about six to seven days, a case manager generally should handle fewer cases, she says.
Take, for example, a medical floor in which the hospital model is specialty-based. Rieve says a rule of thumb is 18 patients per case manager, while in the surgery unit the number could reach as high as 28. Case managers working in mental health units generally can manage up to 25 patients, because they usually work with social workers who handle discharge planning. And then again, a worker’s compensation case manager sometimes has up to 150 patients, given the fact that some cases are active for two or more years and the case manager is not dealing with each case daily.
"It’s just common sense that if you are managing 50 patients actively at any one time, you are not able, time-wise, to do the kind of in-depth case management required for high-risk patients," Erickson says. "People have to be very clear on what they are asking the case management department to achieve."
For people struggling with the issue, Erickson offers advice similar to Rieve’s, saying the ballpark number that nurse case managers are handling runs somewhere between 18 to 30 active cases on any given day. "If that includes UR, then you are probably doing 30 a day and you are [probably] supposed to do UR as well as clinical care coordination. [If you are,] I’ve got to tell you, you are probably not doing very much clinical care coordination."
In the late 1980s, when hospitals began setting up case management programs, "people starting looking around for the quickest, most cost-effective way to put it in place," Erickson recalls. "I think the easiest route seemed to be, Let’s just take our UR staff and give them discharge planning, and then we’ll have a case management model.’"
UR and DP can generate conflict of interest
She says that model is appealing because it looks efficient, but in reality it is fraught with tensions.
"If you are a review person, you have to do reviews in a timely fashion or you lose revenues. But you are supposed to be doing discharge planning, and you shouldn’t be deferring that either," Erickson says. "If those are competing time demands, it almost puts you at a conflict of interest with the patient if you are supposed to review them and keep them certified for care, but you are also supposed to be discharging them.
"There are a lot of models set up that way, and I think there are some issues with that," she says.
Considering the fact that this is an era in which hospitals are struggling financially, they ought to be looking to their case management programs to save them, "but we’re starting to see a troubling trend where a lot of case management programs are getting downsized along with everybody else. It almost seems like an oxymoron that you would downsize the very vehicle that ought to help you be solvent," Erickson says.
She adds that many case management departments have difficulty demonstrating their efficacy. "Part of that is because they are carrying these huge caseloads and they have such diffuse roles, they are doing so many goofy things that they are not able to handle any of that work really well."
The workload prevents case managers from performing their jobs effectively and focusing on outcomes evaluation, evidence-based medicine, and performance improvement. "They probably are better on the UR piece because it is the most functional work," she says. "But what happens with patient satisfaction? How much can they really engage that?"
Specialty-based CMs become experts
Hospitals across the country are attempting to address some of the concerns raised by Erickson. For example, new management at the 400-bed Winchester (VA) Medical Center sees the future for hospital case management as being specialty-based, rather than its former form of unit-based case management. The latter style was implemented in 1989 when the hospital first adopted a case management program.
The unit-based system took case managers throughout the hospital and produced its share of downtime as employees raced around following up on a plethora of diagnoses and managing up to 25 patients at a time.
Switching to a specialty-based system should reduce the number of patients, ideally to a range of 17 to 20. But more importantly, under the specialty-based system, case managers will become experts in their fields, says Christine S. Sytsma, RN, MSN, a heart center case manager at Winchester. When the system is fully functional, Sytsma says the hospital — which is aiming to be a center of excellence — likely will have five different specialty centers including cardiac and possibly behavioral medicine, orthopedic, general surgery, and possibly women and children.
Intensity of the services has a great impact on the number of patients a case manager can handle. At Winchester, for example, case managers’ duties include everything from admissions to discharge planning, with a focus on clinical care and discharge planning. They do receive some help in discharge planning from social workers, who are unit-based. The six full-time social workers at any given time are dealing with four to five case managers.
For more information, contact:
Sue Erickson, RN, MPH, assistant hospital director, Vanderbilt University Medical Center, Nashville, TN. Telephone: (615) 322-5000.
Julia Rieve, president, CQI Healthcare Management Consulting, San Diego. Telephone: (619) 226-4141.
Christine S. Sytsma, RN, MSN, Winchester (VA) Medical Center. Telephone: (540) 722-8000.
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