New responsibilities mean a lower caseload for case managers

Experienced professionals are a must for the job

The Affordable Care Act and other provisions of healthcare reform definitely have shone a bright light on utilization, care coordination, and case management interventions, says Cheri Lattimer, RN, BSN, executive director of the Case Management Society of America (CMSA), based in Little Rock, AR.

"But there’s more on case managers’ plates than ever before," she adds.

One of the issues facing hospital case managers is the short amount of time they have to work with patients and the tasks they are expected to complete, Lattimer points out. "Case managers are being asked to keep tabs on the length of stay, coordinate services the patients receive, create discharge plans, and conduct transitions of care, all in the short time the patient is in the hospital. This is a prescription for disaster," she says.

In many of today’s hospitals, case managers, social workers, discharge planners, and other clinicians are spending too much time in the medical record but are not talking to patients and their families, says Karen Zander, RN, MS, CMAC, FAAN, president and co-owner of the Center for Case Management, based in Wellesley, MA. "Instead of managing care, they are managing documentation. Among clinicians who really enjoy patient and family contact, there is a great deal of mourning about that situation," she says.

Case managers can’t help their hospitals succeed in this new world if they have a caseload of 30 patients; then, they’re just putting out fires and not doing enough critical thinking and collaborating with physicians on the best plan for the patient, adds Toni Cesta, RN, PhD, FAAN, and partner and consultant in Dallas-based Case Management Concepts.

Hospitals must have adequate case management staff to deal with all of the additional responsibilities and to do them well, Cesta adds.

But it won’t help hospitals to add staff if they just put new case managers on the floor without adequate training, says Patrice Sminkey, RN, chief executive officer for the Commission for Case Management Certification, based in Mount Laurel, NJ.

"The industry is going to have to address the need for qualified professionals to be able to meet the new demands or else quality or the care itself may suffer. Case managers need experience, education, and training and should be able to demonstrate that they have the competence and skill set to handle the job," Sminkey says.

And as the healthcare environment changes, it’s even more important for professional case managers to be either RNs or social workers who have the experience and background to manage patient care through the continuum, Lattimer says.

Hospitals need to clarify the role of nurses, social workers, and case managers and to make sure each discipline knows its responsibilities, Zander says.

Sminkey suggests sitting down and looking at the job descriptions for each member of the healthcare team and making sure the right individual is in each position.

Analyze the job descriptions to make sure there is no duplication of effort. "So often services fall through the cracks when two people are dealing with one matter and none are working on another," she says.

Identify core competencies that the case manager needs to perform and what outcomes could look like if the right people are doing the job, she says.

In many hospitals, inpatient and outpatient case managers report to different people, which creates silos and makes it difficult to coordinate services patients receive in each setting, Zander says. She suggests that all of the case managers report to the same person to avoid walls between the two points of care.

Case managers are so overloaded that all they have time to do is fill in one window after another on the electronic patient chart, says Catherine M. Mullahy, RN, BSN, CCRN, CCM, president and founder of Mullahy and Associates, a Huntington, NY-based case management consulting firm.

"They don’t have time to read other people’s input to get a complete picture of the patient," she adds.

Mullahy suggests that instead of having case managers assess every patient, the nurse on the unit should screen patients for case management. "Then and only then should case managers get involved. Seeing every patient is a waste of case managers’ time," she adds.

She recommends developing an acuity checklist that nurses on the unit can use to help screen for patients who need case management. Social workers should be involved with patients who need community services, she says.

"Social workers and RN case managers should work together on complex patients," she says. In today’s healthcare environment, it’s going to take a team approach to provide the care patients need and to ensure safe transitions, Mullahy says.

The hospital culture has to change to meet the challenges of a changing healthcare system, Mullahy says.

"It’s not going to work until hospitals have a dedicated case management department with specific roles. Physicians see case managers as being in charge of utilization review and not as a working partner," she says.

Technology is going to play a huge role in healthcare’s future, but don’t let it replace person-to-person communication, Lattimer says. Resources like the health information system can increase efficiency, she says. But if clinicians don’t know how to communicate as a team and solve problems together, it will have an impact on patient care, she adds.

Develop a team of licensed and unlicensed staff in your case management department, Lattimer suggests.

"There is a tremendous amount of administrative work and telephone calls that do not require an RN or a social worker. Having a case management extender, who is not a nurse or social worker, will free up the licensed professionals on the team to work at the top of their license and scope of practice," she says.

Case management extenders can be trained to make follow-up calls to find out if patients got their prescriptions filled and if they have any questions and then triage any problems appropriately to a nurse, social worker, or pharmacist, she says.

In the new world of healthcare, hospitals need a highly functioning interdisciplinary team in order to succeed, Sminkey says.

"This is an opportunity to talk about how we can work together better. We need to look at the entire healthcare team as a unit, putting patients in the center and optimizing each function for better care, better quality, and better cost," Sminkey says.