Never ask your hospital’s management to approve more staff unless you have the evidence for the return on investment for your request, advises Brian Pisarsky, RN, MHA, ACM, senior managing consultant at Berkeley Research Group, with headquarters in Emeryville, CA.
Being able to convert what case managers do to dollars is critical, adds BK Kizziar, RN-BC, CCM, owner of BK & Associates, a Southlake, TX, case management consulting firm.
“Data is the only thing the C-suite cares about in terms of justification. Case management directors need to provide data, not anecdotal evidence, to make their case,” she adds.
Case management directors have to demonstrate what can be done monetarily in order to increase staff, Kizziar says.
“If case management directors talk to the chief financial officer about patient satisfaction or touchy-feely things, the CFO is going to roll his or her eyes and thank them for coming in, and do nothing about their request for more staff,” Kizziar says.
At one hospital, Kizziar said to the management team, “What would you think if I could save you $200 in costs per patient day, decrease the readmission rate, and increase physicians satisfaction?”
“I had their attention and showed them the blueprint of how I was going to do it. I told them that the case managers have to be at the bedside and round with physicians and talk to families and that they can’t do that when they’re doing utilization review and clerical jobs,” she says.
Her plan assigned utilization review to utilization review specialists who did nothing but utilization review and set up a resource center staffed by non-clinicians to handle referrals for post-acute needs.
Kizziar reports that she has checked back with that hospital occasionally over the past year and the plan is working.
“In order to justify hiring more staff, case management directors have to convince the C-suite that case managers are orchestrating the symphony by making sure that everything gets done for the patient in a timely manner,” adds Christine Babina, RN, BSN, a case management consultant in Oxford, CT.
Determine the cost of an excess stay and demonstrate what it means to your organization if the patient stayed in the hospital longer than needed. Multiply the number of excess days by the cost per day, Pisarsky suggests.
Point out that not only did the hospital lose money on the patient who had a longer than necessary length of stay, it lost reimbursement for the patient who could have filled that bed, Pisarsky says.
Tabulate the number of patients who are being discharged late in the day and show that if you can get a patient discharged earlier, patients waiting in the post-anesthesia care unit or the emergency department can get in the bed quicker. “It improves throughput and helps the bottom line by not having additional expense caring for a patient when you aren’t going to get any more reimbursement,” he says.
Convert your case managers’ actions into dollars, Kizziar suggests. For instance, if a physician orders an MRI and the patient just had one a week ago but the physician hasn’t seen the results, the case manager can show the physician the results and document that she prevented the second MRI. The same is true if physicians order a chest X-ray on a pneumonia patient every day.
“If case managers are busy doing clerical tasks or utilization review, they can’t catch duplicate procedures. That’s the best justification for separating utilization review and case management,” Kizziar says.
Another way to show cost savings by case managers is to show how many patient days were saved by case management interventions, Kizziar says. For instance, if you can show that Dr. X typically keeps pneumonia patients five days but they have been being discharged in three days, you can say it could be because of case management interventions.
“But in order to convince the physician that the patient can do fine at home, a case manager has to be on the floor, talking to the doctor, looking at lab work, and talking to patients to find out about their home environment and whether they could manage at home. Case managers have to interact with patients in order to make recommendations to the physician,” she says.
Time studies are one tool that case management directors can use to make the case for new employees, Babina says.
To develop a time study, have all your case managers keep a log with them at all times for a week and document every 15 minutes what they are doing and how long it takes.
“Often they don’t get to eat and frequently their days are more than eight hours. If a patient is ready for discharge at the end of the day, they can’t just go home. Otherwise, they’ll be increasing the length of stay and financial ramifications. Case management directors need to be able to demonstrate the long hours case managers work,” she says.
At the end of the week, take the logs of all case managers and break each job into steps, she suggests. Add together the time each job takes, then get the median time for each job. “It brings to light what their job is. This way, if they came in at 8 a.m. and didn’t leave until 6 p.m., they’ll have it written on paper,” she says.
Make a note if case managers are doing things that aren’t part of their job description, such as assisting patients to the bathroom when there is no staff nurse available.
In one case, Babina persuaded the chief financial officer to shadow a case manager to see what a typical day was like.
“Nobody realizes what a case manager’s job entails. The CFO was surprised at how much case managers are expected to do. In this case, it became clear that we needed additional help in the case management department,” she says.