Hospital case managers are being asked to take on a bigger, more important role — but, in many cases, staff is not increasing, leading to high caseloads, low morale, and burnout.
• Case management leadership must be cognizant of what their staff faces daily and make the case to hospital management for hiring more full-time employees in the department.
• Analyze your needs before recruiting, be aware of the characteristics needed to fill the spot, and involve front-line staff in the hiring process.
• Create a robust orientation, training, and mentoring program to prepare new case managers for their own caseload.
• To improve staff satisfaction, recognize case managers’ achievements, celebrate Case Management Week, and hold retention interviews to gauge staff’s likes and dislikes.
As payers shift their emphasis to quality of care and tighten reimbursement, case managers are becoming more essential than ever before to hospitals’ survival.
Case managers now have a much bigger role in healthcare organizations, says Vivian Campagna, RN-BC, MSN, CCM, chief industry relations officer for the Commission for Case Manager Certification (CCMC). “Hospitals are looking for lower costs and better value, and case managers are playing a big role in achieving that,” she says.
While the need for case managers in the hospital is increasing, the case management workforce is aging and older case managers are leaving the profession, Campagna says.
She points out that 10,000 baby boomers are retiring every day, and case managers are among them. Some seasoned case managers who are reaching retirement age are looking for jobs that don’t require them to work full-time, she adds.
The median age range was 55-59 for the largest group of board-certified case managers responding to Health2 Resources and CCMC’s January 2017 Professional and Demographic Characteristics of CCMs survey, Campagna reports.
“In response to payer regulations, hospitals are adding more responsibilities to the case management role but aren’t adding any more FTEs [full-time equivalents]. This is adding to the increase in burnout for many case managers,” says Mindy Owen, RN, CRRN, CCM, principal owner of Phoenix Healthcare Associates in Coral Springs, FL, and senior consultant for the Center for Case Management.
Some case managers are leaving the profession because they feel the department isn’t supported by the C-suite leadership, Owen says.
“They are told they have to add certain tasks to their daily workload, but they feel there is a lack of understanding and support as to what impact it has on the overall role case management plays. Job satisfaction isn’t there and they’re looking elsewhere in healthcare for a role that is less stressful and is seen as more supported,” she adds. For instance, case managers may carry a caseload beyond realistic expectations for extended periods of time, and they may feel defeated and start burning out.
“Management doesn’t understand the reality that their staff is burning out, the unrealistic expectations, and therefore is reluctant to make adjustments,” she says. (For tips on improving staff satisfaction, see related article in this issue.)
Even with the emphasis on care coordination and recognition of the value of case management, case managers are still being asked to do more with less, says BK Kizziar, RN-BC, CCM, owner of BK & Associates case management consulting firm in Southlake, TX.
“When we talk to clients, we’re finding more and more that the role of case manager is critical. But because case management is such a vital role, in many hospitals case managers focus on many components of the episode of care and become the jack of all trades and the master of none,” adds Tina Wiseman, MEd, chief administrative officer of Novia Solutions.
“To be effective in today’s healthcare world, case managers have to become familiar with all the details of the cases and nuances of the patient’s situation in order to determine how patients need to progress. They have to focus on the hospital stay, transition to the next level of care, and even after that,” Kizziar says. But in many cases, they simply don’t have the time to do so, she adds.
If case managers partner with the treating physicians to ensure that patient needs are met during and after discharge, it can have a huge effect on length of stay and reimbursement, Kizziar adds.
But, too often, case managers either don’t have the opportunity to communicate with physicians except by sticky note, which can be ineffective, or physicians are not open to communication, she says.
Case management departments are more successful when they are supported by a strong physician advisor program inside the department, Owen adds. For example, there are occasions when case managers know patients are ready to be discharged but the attending physicians may not be willing to complete their part of this process for a variety of reasons.
“If the physician advisors are not willing to intervene in a timely manner with their peers about the transitions of care, case managers feel frustrated and unsupported,” she says. On the other hand, when physician advisors are a collaborative arm for both the case managers and their peers, the process is more successful, she adds.
Part of the problem is that many case management departments suffer from a lack of strong leadership and a commitment to what case management should be and how it is practiced, says Catherine M. Mullahy, RN, BSN, CCRN, CCM, president and founder of Mullahy and Associates, a case management training, education, and consulting firm in Huntington, NY.
Mullahy reports that she and her team frequently hear from case managers who are concerned that their leaders are not knowledgeable about the essential activities that case managers should perform, and are not familiar with the Case Management Society of America’s standards of practice.
“These case managers share that most of their time is spent on phones or at their computers, so they have minimal time to actually have conversations with their patients,” she adds. Many also complain of large caseloads and report feeling overwhelmed, frustrated, and disheartened, she adds.
In some cases, the hospital administration is directing the department to concentrate on matters other than care coordination, such as compliance issues, documentation, and other regulatory matters, she adds.
“When we have leaders who are more influenced by hospital administration than adhering to the principles of good case management, it’s no wonder why there are staff shortages and staff burnout,” she says.
Case management leaders must be passionate and committed to the practice of case management, Mullahy says.
“This should be evident in their ability to strongly represent and communicate to senior management the role of case managers, their goals, their concerns, and the quality, safety, and overall experience of care the patients are receiving,” she says.
Case management leadership should be aware of daily staff issues and should stay informed about all of the changes occurring in healthcare, Campagna says. “A lot of new rules and regulations that affect case managers are coming down the pike. It’s really important for case management directors to stay on top of what is happening so they can determine how the case management process in their departments needs to change to meet these requirements,” she adds.
Case management directors must be aware of payer requirements from a compliance and risk management perspective as well as from a revenue perspective, Owen says. “If the case management director is not on the top of his or her game and doesn’t understand all the complexities and impact the regulations can have on an organization, the hospital is likely to lose revenue and encounter risk management issues,” Owen adds.
She points out that Medicare audits can have a huge effect on hospitals if case management leadership is not on top of the regulations. “Compliance with payer rules and requirements weren’t as impactful years ago as they are today, but in today’s world it is the case management department that is looked to for understanding, guidance, and collaboration with risk management and quality to maintain compliance for the facility or health system,” Owen says.
It’s up to case management leadership to make sure the hospital administration understands how healthcare and reimbursement are changing and how the changes affect case management, Campagna says. They must show hospital leaders how case management affects quality and safety, she says. “Educate management that CMS is looking at how well hospitals provide case management service and how positive their outcomes are,” she adds. (For more on how to justify adding staff, see related article in this issue.)
Case management director roles are vacant or have a high turnover rate and there aren’t a lot of candidates with the experience and expertise needed, Owen says.
“There’s not an abundance of experience out there to take on the director role. There’s a huge group of case managers who are considering retiring, but there hasn’t been a lot of mentoring to prepare younger case managers for management positions,” she says.
One problem is a lack of understanding on the part of the hospital’s senior management about what is needed to be a successful case management leader, Owen adds.
“A lot of organizations go back to the theory of ‘a nurse is a nurse is a nurse’ when they fill case management leadership positions. But the head nurse on a nursing unit isn’t prepared to transition easily into being a case management director,” Owen says.
She points out that the case management process requires a specialized skill set that bedside nurses don’t necessarily possess. Case management directors also must be knowledgeable about regulatory requirements from Medicare and contractual obligations from third-party payers, and none of this is a focus in nursing programs today, she adds.
There is a trend in academia toward post-baccalaureate and master’s programs for case managers, Campagna says. “It’s similar to the training for an advanced practice nurse. Case management is beginning to become more of an advanced practice, and people are recognizing that,” she says.
Campagna urges case management directors and experienced case managers to nurture and mentor young case managers to help them develop the skills needed for successful outcomes for their patients.
CCMC has seen an increase in the number of younger people, particularly millennials, who are becoming certified, she adds.
“Part of CCMC’s goal is to encourage younger nurses and social workers and get them interested and excited about case management,” Campagna adds.