Optimal caseloads depend on a variety of factors

Role function, model design, payer mix considered

The functions that case managers perform in your hospital can have a big effect on the caseload they can comfortably handle, says Toni Cesta, RN, PhD, FAAN, vice president for patient flow optimization at the North Shore-Long Island Jewish Health System.

"People often ask me what are the right numbers for a case management caseload, but it depends on so many other issues, such as the role function and how the department is organized. Case management directors have to create a balance between the number of functions a case manager handles and the number of patients he or she can manage and still do a good job," she says.

The number of patients for whom a case manager can coordinate care depends on many factors, including case management role function, the department's model design, payer mix, and intensity of services, Cesta points out.

Start by looking at the number of functions that case managers do or do not perform at your hospital, she suggests. These are likely to include:

  • coordination and facilitation of care;
  • utilization management;
  • discharge planning;
  • variance identification;
  • quality management/core measures;
  • documentation improvement.

Typically, if case managers on a medical/surgical unit are responsible for more than three of the functions, their caseload should not exceed 15, Cesta says. If they are responsible for three or fewer functions, they can handle a caseload of up to 20, she adds.

"In other clinical areas, like obstetrics, case managers could handle a higher number of cases," Cesta says.

However, there are other factors to take into consideration, such as the model design, including the relationship between nurse case managers and social workers, how many there are of each and who does what; weekend and evening coverage; coverage for vacations, holidays and sick time; and what areas the case managers cover in addition to the units, such as admitting and the emergency department.

Patients with high cost and high length of stay typically take up a lot of a case manager's time, and these case managers should have a smaller caseload, Cesta advises.

If you work at a small community hospital where complex patients are transferred to larger hospitals, your patients are likely to need lower intensity of service and case managers can handle more patients, Cesta says. On the other hand, tertiary care hospitals typically treat patients with more intense case management needs, and case managers should have lower caseloads, she adds.

Length of stay also affects the case manager load, Cesta point out.

"Some patients may have a short length of stay and need a quick turnaround on discharge planning. Patients with a longer length of stay may need more coordination of care and more complex discharge planning," she says.

Payer mix also can affect the workload a case manager handles, Cesta points out. Managed care patients typically need more utilization review and more calls to third-party payers. On the other hand, Medicare patients tend to have complex needs and comorbidities and need a lot of discharge planning. Medicaid patients are likely to have more psychosocial and financial issues than other patients.

Other factors to take into consideration include whether the case managers have clerical support staff to take care of paperwork and whether they can use a case management software program, rather than doing documentation and other paperwork by hand.