By Melinda Young

No matter what size a hospital and case management department are, there are difficulties in finding the right level of staffing.

“Leaders all over are challenged with this,” says Mickey O’Neill, MA, RN-C, CMAC, CCM, director of care management at Women and Infants Hospital in Providence, RI.

There is no one-size-fits-all approach because each hospital has its own expectations and sensitive situations in which case management might be needed.

“There might be providers who require things that are not standard for a case management department everywhere, but some hospitals will lean in that direction,” O’Neill notes. “They also have to evaluate the overlap between case management and other departments.”

The goal should be to have case managers work to the full capacity of their skills and abilities, she adds. “Think about what exactly case managers are doing that really requires someone with that license,” O’Neill says. “One example is follow-up appointments. Although a lot of case managers schedule follow-up appointments, is that required for a nursing license?”

There are some methods that case management directors can use to ensure the most efficient staffing levels and expertise. O’Neill suggests the following:

• Visit units. “Shadow case managers, go to their units, and ask about their workflow and how they organize their day,” she says. “It’s important to have informal time to find out what their pain points are and how they experience their challenges.”

For example, it might be inefficient to use case managers for precertification of medications when the insurance company often wants to talk to the doctor and not the case manager, O’Neill says.

“We did a project, working with our hospitalist team, to streamline that process,” she explains. “Nurses were spending so much time trying to talk to insurance companies to justify medications when they weren’t the prescriber.”

The solution was to develop standardized forms and processes, including outlining when it would be necessary to ask a physician for input. “Part of it was getting contact information for providers to call and setting an expectation that they needed to be the ones to get on the phone, and we’d help them with the phone calls,” O’Neill says. “It worked.”

Another benefit to spending time with staff is it helps a manager find out which employees have computer access to certain information, she says. One unit’s case manager might have figured out to create an easy and smooth workflow. Another case manager on another unit might be struggling with this because of technology knowledge or access barriers, she adds.

By visiting case managers in the units, a manager can distribute best practices between case managers on different units. “There’s always a challenge to make sure all staff has consistent computer access, but it’s talking about work processes with the individuals and helping to facilitate the IT access they need,” O’Neill says.

• Perform a time study. “Another way of assessing on units is to have staff do a time study,” she says.

Employees might not like this because it is time consuming and requires them to write down what tasks they are performing every 15 minutes. “Then, you code it and see where employees are spending their time, including computer time, face-to-face time with patients and families, or making phone calls when something is not right,” O’Neill says.

• Build teams. “It’s really important to take the time to spend with the team and for the team to spend time together, sometimes just doing things that are fun,” O’Neill says. “It makes it a lot easier if people need to float to different units or cross-train. When you’re looking at all hands on deck, I think team-building helps with staffing.”

• Adjust staff numbers. “It takes thoughtfulness to adjust the numbers of staff,” O’Neill says. “You have to know what your needs are.”

For instance, some specialty units might require a different case manager ratio. “Disease-specific units and intensive care units have the capacity to take less time from case management,” she says.

“Once you know how many hours per week it takes to just cover your basics, then you also need to have a plan for what the contingency is and how to meet that level of necessary staffing and move people around,” she adds. “On the flip side, you have to think about the difference between how many hours people work vs. how many hours they are paid. You have to plan for meetings, vacations, education, and different projects they might be involved in.”

Start at their total hours of paid work time for the week and work backward, subtracting for all those activities that take them away from their basic workday activities, she advises.