In many hospitals, senior management does not understand the importance of the case management role until the hospital is audited and penalties are assessed, 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.
“Senior management becomes engaged because the hospital is taking a financial hit. That’s when it’s time to make the case for the tools, department structure, and an alignment of FTEs [full-time equivalents],” she adds.
To justify adding staff, case management leaders must speak a language that the C-suite understands, and that is finance, adds BK Kizziar, RN-BC, CCM, owner of BK & Associates case management consulting firm in Southlake, TX.
“Management may appreciate anecdotal accounts or subjective information, but it’s not going to convince them to spend money,” she says.
Case management directors must show solid clinical data to educate hospital leadership on the role of case management, what case managers contribute to the bottom line, and what the department needs to function effectively, says Vivian Campagna, RN-BC, MSN, CCM, chief industry relations officer for the Commission for Case Manager Certification.
“When making the case for additional staff, the case management director needs to acknowledge what the investment of the hospital will be — but also show the return on investment. Management has to understand that increased staff and lower caseloads mean that case managers can do better management of the acute care episode and transition plan, which helps to prevent readmissions and helps the hospital avoid readmission penalties,” she says.
There’s no magic number for determining the ideal caseloads. “It depends on the job description and the case management model,” Owen says.
“It’s hard to pinpoint a benchmark for caseloads. It depends on the acuity of patients, whether or not they have insurance, and other factors. It may take an entire day to plan one discharge, while other discharges can be handled in a shorter period of time,” Campagna adds.
There’s a fine line between the financial and the clinical aspects of healthcare, and case management directors must be on top of both, Kizziar points out. Case management directors need data to demonstrate the savings and avoided costs because of case management interventions, she adds. “It’s critical to convert what case managers do to dollars,” Kizziar says.
Work with the hospital’s financial team to obtain the data needed to demonstrate how much case management interventions can save, Kizziar suggests.
“Financial staff may not necessarily be able to provide the cost for a service, but they can provide the charge for the services delivered. If this is the case, case management leadership should ask for the cost-to-charge ratio and use that to come up with financial data,” Kizziar says.
For instance, if a service is charged at $100 and the cost-to-charge ratio is $20, you know the service cost the hospital approximately $80, she says.
Look through the charts for duplicate services, such as daily chest X-rays on pneumonia patients or repeated tests. Add up the costs and point out that case management interventions could have prevented the duplication.
Track the number of patients who stayed in the hospital longer than needed and multiply the number of excess days by the cost per day. At the same time, tabulate the days that were saved by case management interventions, and multiply that by the cost per day.
In your presentation, include examples of when a case management intervention could have saved money, Kizziar adds. An example might be a case where three specialists were consulting on a patient and the attending physician wouldn’t discharge the patient until the specialists approved, so the patient stayed an extra day.
“The case management director can tell hospital leadership that the problem could have been avoided if the case manager had been coordinating care for the patient and making sure the consultants act in a timely manner. Then, add that the case managers can’t coordinate care very well if they have a huge caseload,” Kizziar says.
Compare the rate the hospital receives for reimbursement to the cost of care to determine if the hospital can meet patient needs and successfully transition patients at a reimbursement rate that helps maintain operations, Kizziar says.
“Hospitals can charge whatever they want, but it’s what they get paid that counts,” Kizziar says.