Time Management for Case Managers — So Much Work, So Little Time
By Toni Cesta, PhD, RN, FAAN
It seems that every year case managers are asked to take on more and more roles and functions. Every time a new rule or regulation comes out from the Centers for Medicare & Medicaid Services (CMS), administrators turn to case management as the group to take the new problem or task on. This translates to more work! How many of us have heard the age-old phrase, "Give it to the case managers. They’re already in the charts."? This kind of logic is a throwback to the time when case management was actually utilization review, and utilization review managers (case managers) spent their workdays reviewing medical records. But times have changed, and now case managers are an integral part of the interdisciplinary care team. As with any professional group or specialty, there is a finite amount of work that case managers can do, and do effectively, with positive outcomes for their patients and the organization they work for.
This dilemma is twofold. First, it represents a serious disconnect between health care administration’s understanding of the work we do. Second, it represents case management’s own lack of ability to be able to articulate what we do and how it affects the quality of care, the cost of care, and patient outcomes. Some of it comes from a need and desire to "prove" our worth to our organizations and the thought that taking on more and more work would somehow accomplish this. By never questioning additional workload, this can give the appearance that we have all the time in the world and can endlessly take on more and more. So we do have a hand to play in this problem.
Having said that, I think things are getting better. More and more administrators are gaining an appreciation for, and understanding of, what case management can do to better the functioning of their organization. Many are beginning to see the dynamic role that case managers must play as part of the interdisciplinary care team. However, many still do not understand what appropriate case loads are or how the work must be managed on a day-to-day basis. We have discussed appropriate caseloads many times, but case managers still struggle with how to manage the amount of work that needs to be done on any given day.
This month, we will discuss some strategies for managing workloads. We will do this under the premise that your caseloads are appropriate to your case management model. No matter which model you have, if your caseloads exceed 25 patients, then they are too high and you cannot possibly perform true case management. The sweet spot is between 15 and 20 patients, depending on your roles and functions. So, assuming that is your caseload range, we will review how a day can be organized, and what you can do to make your workday productive and enjoyable for you.
A Routine for the Hospital Case Manager
To understand the work flow for a case manager, we need to first understand that the work we perform in the case management process is not linear. Linear work, such as that performed in a factory for example, follows a course that is not deviated from. As Toyota builds a car, the process of car-building follows a strict algorithm, and any deviation is considered a failure in terms of quality. In our work as case managers, we need to follow a process, but we also need to appreciate that sometimes work has to be repeated. This means that we sometimes have to circle back to functions we have already performed and either repeat them or perform them in a different way or in a different order.
Despite the fact that our work is not linear, we still need to have structure to it. A work structure is important because it ensures that we don’t forget anything or unnecessarily repeat work. So, organization is the name of the game. Keeping yourself organized is the surest way to complete your work and get satisfaction from completing it.
Overall Structure for the Day
As health care professionals, we know that every day will be different and that each day may bring new and different challenges. By organizing your day, you will allow room for the unexpected snags that will invariably come up. When you were a staff nurse, your day was organized around medication administration, treatments and paperwork. As a case manager, the work functions are different and do not immediately lend themselves to a time structure. Nevertheless, some of what we do is time-limited. By this I mean that some routine work must be completed by a certain time of the day. Examples of this include clinical reviews, today’s discharges, and daily rounds.
Organizing Your Patient Assignment Use a Binder!
One of the tools that can be very helpful to you is a binder with your patient’s "face sheets" in it. Depending on the case management software that you use, there may be a different name for this document. The document should include the patient’s demographics such as address, insurance information, next of kin, and so forth. The binder should be organized with a section for each of your patient’s face sheets. Each section should represent a bed number. You can use this face sheet in the binder to jot down anything you need to remind yourself to do for that day or during the course of the hospitalization. You can take it on rounds with you and refer to it. You can refer to it when asked a question about one of your patients. It is impossible to remember everything, and things move very quickly. By jotting down notes to yourself, you don’t need to spend wasted time trying to remember things or running back to the electronic medical record (EMR) every time you need to refresh your memory.
Once the patient is discharged, you can simply discard the form as it is not a permanent part of the medical record.
Organizing Your Day
Let’s plan our day around an eight-hour shift. If your day is longer or shorter than this, you can adjust accordingly. Let’s also assume that you have some version of case management software. If you do not have case management software, then you can still obtain the data sets we will be discussing through your information technology (IT) systems.
8:00 am 9:30 am
• Report to your assigned unit or area.
• Print and check the patient census for your unit or assigned beds. You should have your case management software configured so that you can print out your assigned area with little difficulty every morning. If you don’t have case management software, then your admission/discharge/transfer (ADT) system should be able to create a similar census report for you daily.
• Review the patients in your assigned area. Identify which patients were newly admitted or transferred to your unit since yesterday, and which patients were discharged since yesterday.
• Print face sheets for new admissions or transfers and place them in your binder, as we discussed above.
• For patients transferred to your unit, request report from the transferring case manager.
• Review your notes from the day before to see what tasks you left for completion today on existing patients.
• Review the medical records of any patients new to you, including transfers and new admissions. As you read the medical record, review the following data sets:
What brought the patient to the hospital?
Was this a 30-day readmission?
Is the patient insured? By whom?
What are the patient’s support systems?
Where does the patient live?
What is the expected length of stay?
If available, review laboratory, diagnostic and other test results.
Review physician and nursing notes.
Identify the patient’s route of entry to the hospital.
• Jot down any questions or points of clarification you may have for the interdisciplinary care rounds.
9:30 am 10:30 am
• Interdisciplinary care rounds take place during this time slot. They should occur daily at the same time.
• Rounds may take place in a conference room, or you may have walking rounds. Walking rounds are considered best practice and are a much more efficient and effective way to conduct rounds.
• If you are conducting walking rounds, bring your notebook with the face sheets in it. Have your questions ready for the interdisciplinary team. Core team members should be on rounds including the physician, the staff nurse, the nurse manager, the case manager and the social worker, if possible. As discussed in prior months, the case manager and social worker should provide relevant information on rounds, including the expected length of stay, the anticipated discharge plan, and any barriers to care or discharge such as insurance issues or family dynamics. This is also your opportunity to gather additional information on the patient and ask any questions of the rest of the team. Rounds are an opportunity to give as well as receive information.
• Once the patient has been reviewed in the hall, the team should go into the patient’s room and introduce themselves. Allow the patient to ask any questions, but set time limits. If the patient needs additional time, tell the patient that you will come back after rounds are completed.
• Review the patient and their environment visually. Check the patient’s affect and mental status. Check for intravenous lines, Foley catheters, or other drains or devices. Ask them if they have gotten out of bed, and if they have eaten. This will help you when you do your clinical review later.
• Make a note of any additional information you may need or referrals you may need to make.
• Request any discharge orders for the day that have not been written.
• Request any physician orders that need to be written.
• Complete your admission documentation on newly admitted patients. Use your case management admission form.
• Refer any cases that meet psychosocial high-risk criteria to the social worker.
10:30 am 10:45 am
• This may be a good time to take a fifteen minute break, if possible.
10:45 am 12:00 pm
This can be the busiest time of the day for case managers. Both discharging of patients and clinical reviews will need to be completed.
• Begin the discharge process for patients leaving today. Be sure that you have discharge orders for the day’s discharges.
• Ensure transportation has been arranged and ask nursing to complete discharge paperwork. Discuss any last discharge issues with the patient/family.
• Your goal should be to have today’s discharges out of the hospital by 12 noon whenever possible. Some patients may have to stay later if a diagnostic test result is pending. Facilitate obtaining those results so that the discharge can be expedited.
• During this time slot, you will need to complete clinical reviews for those third-party payers who require their review by 12 noon. You should know what your cut-off times are for each payer and adjust your work accordingly. If you do not complete the clinical review by the expected time, as per your contracts, you risk a denial of payment to the hospital.
• Based on your admission assessment and/or daily assessment, make referrals to home care as appropriate.
• If any patients are going to other levels of care, such as acute rehab, sub-acute or long-term care, discuss their options with them. For skilled nursing facilities and home care, give them the list of choices of agencies and facilities and let them know that you will come back later in the day to discuss their choices and answer any questions they may have.
12:00 pm 1:00 pm: Lunch Break!
1:00 pm 2:30 pm
• If any tests, treatments, consults or other referrals are delayed, expedite these by contacting the appropriate department or discipline.
• Identify tomorrow’s discharges and obtain discharge orders and prescriptions when possible.
• Conduct any discharge education needed to prepare patients who are pending discharges.
• Alert the staff nurse to pending discharges so that clinical education can be completed.
• Order transportation as needed and/or notify the family of the time they should arrive to pick up the patient.
• Provide a verbal as well as written handoff to the next level of care.
• Complete any additional clinical reviews, particularly Medicare patients.
• Review the "choice list" with any patients who received the list that morning and/or provide a list to any patients newly identified.
• Document progress notes in medical record.
2:30 pm 2:45 pm: Fifteen Minute Break
2:45 pm 3:00 pm: Conduct "Mini Rounds."
This is a good time in the afternoon to conduct mini-rounds. Mini-rounds are a quicker, less detailed version of the morning rounds with a smaller number of team members. The purpose of these rounds is to follow up on any issues that arose during morning rounds that needed a quick intervention and resolution. For example, a patient may have needed to have an MRI expedited. During rounds, whoever was responsible for this can report on the outcome.
The case manager, social worker, staff nurse, and case manager should participate in these rounds. They can be done quickly and informally. Only the patients who had issues from the morning are discussed, so this is a small sub-set of all your patients. Mini-rounds help to save time because by planning to have them every day, you do not need to chase after team members throughout the day to give or receive updates. You can wait until mini-rounds to close the loop on any of these issues.
3:00 pm 4:00 pm
This is the time to wrap up your day. Any remaining issues should be completed at this time.
• Review your caseload and be sure that you have completed everything you needed to for the day.
• Be sure that you have documented in your patient’s medical records where necessary.
• Continue with any needed patient education regarding the discharge plan.
• Talk with any family members who may be present at the patient’s bedside.
• Make any needed follow-up phone calls to patients discharged on the prior day. Ensure that they received any planned-for services and answer any questions they may have. Ask the following questions:
Did home care arrive?
Did durable medical equipment (DME) arrive?
Are you taking your medications as prescribed?
Do you have any questions regarding your medications?
When is your next doctor’s appointment?
Do you have a way to get to that appointment?
Do you have any questions?
The world of a case manager is a busy one, and you may not have all the resources you need each and every day. If you can maintain a routine it will make the workload more manageable for you and will allow room for those surprises that invariably happen. Whether you are a new or a seasoned case manager, organizing your workload can always help smooth out the rough edges in anyone’s hectic day!