Experts: Lower caseloads when case managers take on more tasks

When the role is diluted, patient care coordination may suffer

It's happening all the time at hospitals across the nation. When a new initiative, like DRG assurance or clinical documentation improvement is developed, it's turned over to the case managers "because they're already in the charts."

As a result, many case managers already have more than they can handle, and because they're pressed for time to complete utilization reviews and discharge planning, their direct contact with patients may get short shrift, says Toni Cesta, RN, PhD, FAAN, vice president for patient flow optimization at the North Shore-Long Island Jewish Health System.

"Some directors don't push back when other jobs get loaded onto the case managers. They feel like taking on additional duties will add value to the department, but when it fails, it does the opposite," she says.

When someone has too many tasks to complete in a day, they can't do them all well, Cesta points out.

"There seems to be a myth that you can keep giving more and more tasks to case managers and they'll get it done, but when the role is so diluted, very little does get done well," she says.

The problem of increasing caseloads for case managers is compounded by the fact that many hospitals do not staff case management departments to allow for holidays or the inevitable employee absences, Cesta says.

"Hospitals never budget for nursing staff without having positions to cover sick days. In case management, when someone goes on vacation, is sick, or has jury duty, somebody else has to double their caseload to take care of the work," she adds.

Even when case management departments start out being staffed with good patient-case manager ratios, the department gets behind when some staff wind up with double assignments, Cesta says.

When Cesta talks to case managers across the country, most tell her that they're comfortable with their caseload as long as everyone is working and they don't have to take on extra work.

"Many hospital administrators haven't caught up with the issue of case management caseloads. The department will always be running behind if staffing doesn't allow for vacations and sick time, but there are only a few places that budget for off time for staff," Cesta says.

When Cesta was a case management director, she budgeted for three additional case managers who floated around to the vacant positions.

"Even with three, there was never enough. We still ran with no coverage in some areas occasionally," she says.

Sarasota (FL) Memorial Hospital budgets for 1.5 full-time equivalent case management floating positions to cover vacations and absences, according to Judy Milne, RN, MSN, CPHQ, executive director for quality and patient safety.

The case management department converted some of its per-diem slots to the full-time float positions.

No magic formula

At Sarasota Memorial, clinical case managers who are registered nurses and psychosocial case managers who are social workers work together on the units with the psychosocial case managers assuming most of the responsibility for discharge planning.

"Before we had the clinical case manager float, the case managers were getting stretched more than the psychosocial case managers," Milne recalls.

There is no magic formula for assigning case manager caseloads, and it varies according to how the case management department is organized and the role function of case managers, Cesta adds.

The number of cases a case manager can handle depends on how the department is organized and the role function of case managers, she says.

"Case managers can do a lot of things if they have a small caseload. There has to be a balance in the number of functions and the right number of cases a case manager has to manage," she says.

For instance, a pilot project that decreased the patient-case management ratio from 30-40 to 16-22 was so successful that Our Lady of the Lake Medical Center in Baton Rouge, LA, hired three additional case managers and reduced the caseload on the medical units.

How patients are assigned to case managers also can affect the caseload. Unit-based case managers, physician-aligned case managers, and disease-based case managers all could potentially have very different caseloads, Cesta says.

For instance, St. Vincent's Medical Center in Jacksonville, FL, realigned its case management model to assign case managers by physician. The change lasted just one week.

"We had anticipated that case managers could round with the physicians, get to know them, and have more impact on practice patterns. It worked well with orthopedists, neurologists, and other physicians whose patients were all on one unit. It didn't work well at all for internists and some specialty groups because the patients were on numerous units and the case managers lost a lot of time in transit," says Jamie Zachary, LCSW, the hospital's director of care management.

The case managers at St. Vincent's are responsible for utilization review with the help of clerical staff who get the requests from the insurance company and forward them to the case manager. The case manager conducts the review and sends it electronically to the clerical person, who sends it to the insurance company.

Documentation enhancement and core measures assurance is handled by the medical staff and the quality improvement department.

Caseload assignment

Case manager caseloads at St. Vincent's are based on the needs of the typical patients on the unit and the duties assigned to the care manager compared to the duties of the social worker. For instance, the hospital has a large cardiac program that serves many patients from South Georgia.

"These patients require a lot of intervention because they are from out of state. It is more difficult to set up someone from another state with home health, durable medical equipment, and other post-discharge services or post-acute placements," Zachary says.

Two case managers are assigned to the 30-bed cardiac unit. On other units, where the patients' needs are not as intense, caseloads typically run from 26 to 32.

"Caseload assignment depends on the acuity of the patients. We gather information electronically and know what services patients need on each unit," Zachary reports.

The hospital's case management software tracks the number of reviews, the type of reviews, the length of time each review type takes, and any discharge needs of the patient.

"If the patients on a particular unit typically need home health services or placements, we know that more time is needed and we need a lower patient-case manager ratio," Zachary says. The hospital has been using data from its case management software program to assign case managers since 2002.

"Before that, we made assignments based on our gut feelings and statistics that we kept manually," she says.

Originally, the hospital assigned only one case manager to the cardiac unit, but when the data showed a tremendous volume of patients and a lot of case manager tasks, the second case manager was assigned.

Smaller units at St. Vincent's have only one case manager who does the initial review within 24 hours of admissions, refers the patient internally for teaching, and coordinates any home health or durable medical equipment needs, working with the social worker assigned to that unit on complex cases.

On larger units, there are two case managers who conduct the assessment and social workers who handle the patient's discharge needs. The case managers are cross-trained to take care of the patient's needs for home health, durable medical equipment, or post-discharge placement if necessary.

Sarasota Memorial Hospital uses a dyad model for case management. Medical necessity review is the main emphasis of the clinical case managers.

"We emphasize medical necessity or utilization review for the clinical case managers. They handle less complex or clinically oriented discharge planning. The psychosocial case managers handle most of the discharge planning, particularly the complex cases," she says.

The case managers don't necessarily see every patient every day. They review all patients after admission and schedule a follow-up review at an appropriate interval, which may be every day in some cases.

The hospital's database tracks case manager caseloads and has a built-in complexity factor for discharge planning.

"We constantly look at our statistics to get a feel for the workload and complexity of patients the staff are dealing with," Milne says.

The hospital operates under a dyad model with one clinical case manager and one psychosocial case manager on almost every floor. One large medical unit has one clinical case manager and two psychosocial case managers. A cardiology unit has just the opposite — two clinical case managers and one psychosocial case manager.

"On the cardiac unit, discharge planning is not that complex, but throughput is a big issue, and the utilization review load is heavier than for many other patients. Even with two case managers, we sometimes feel stretched," she says.