Case managers can’t do what is necessary to help their hospital succeed under the new global payment models if they are busy juggling care coordination for 25 or 30 patients, says Toni Cesta, RN, PhD, FAAN, partner and consultant in Dallas-based Case Management Concepts.

“Case managers have to have time to perform the care coordination piece, to think more carefully about the next level of care, and to take the time to put a good discharge plan in place, rather than doing the discharge planning at the last minute. If they have a large caseload, they’re just putting out fires and not doing enough critical thinking and collaborating with physicians on the best plan for the patient,” she says.

Bundled payment arrangements make it mandatory for hospitals to work closely with post-acute providers and to be familiar with the services each provides, and their quality metrics, adds Beverly Cunningham, MS, RN, partner and consultant in Dallas-based Case Management Concepts.

“For case managers to develop relationships and be collaborative with the outpatient environment, their caseloads need to be appropriate. If they are managing the care of 25 to 30 patients, they won’t have the time,” she says.

Case managers have to have the time to conduct an in-depth assessment of their patients to find out their support systems and identify their discharge needs, Cunningham adds. “This information is crucial in developing a successful discharge plan, but case managers can’t spend the necessary time if they are inundated with other tasks,” she says.

It’s not that case managers don’t want to do a better job, Cesta says. It’s just that they have had so many duties piled on them that they don’t have time to do everything well, she adds.

“The majority of case management directors in the hospital setting have the same concerns. They are worried about having adequate staffing to handle all the additional responsibilities heaped on them in this new world of reimbursement, and to do them well,” Cunningham says.

She advises case management directors to talk to the hospital management about appropriate caseloads and to identify an executive sponsor of case management who understands the needs of the department, and can advocate for staff increases.

“If case management departments don’t have adequate staffing and executive support for staff, all they can do is hit the high points. They won’t have the time to think about what happens to the patient beyond the door of the hospital,” she says.

It’s sometimes a challenge to get hospital executives to understand why the case management department needs more staff, Cesta points out.

“They don’t realize how case managers can help the hospital’s bottom line as payers shift their emphasis from fee-for-service to quality. Some of them still just don’t get it,” she adds.

Cesta recommends analyzing the workload, roles, and functions of social workers and nurse case managers, and re-engineering the case management department to align with the continuum of care and payment structure. “There is so much opportunity to develop strategies now that will prepare for the future,” she says.