Acuity system keeps CM workloads on an even keel 

Cases are assigned by needs of members 

A system that rates cases by acuity level helps case managers at BlueCross and BlueShield of Oklahoma (BCBSOK) keep their workload evenly distributed.

Cases are stratified by complexity, with Level 1 being the lowest acuity and Level 5 the highest.

"We know that in case management, you can’t say that everybody has 42 cases; some may have time on their hands, while others may be working overtime. This system helps the case managers maintain a caseload level that will enable them to provide clients with high-quality, cost-efficient services," says Kathy Edwards, BSN, RN, manager of utilization management for the Tulsa-based insurer.

Each case manager carries a load of 40 to 60 cases, depending on the acuity level. Cases are categorized according to the acuity level of case management services, patient needs, and involvement the case manager will have in the case.

For instance, members at Level 1 may need only a weekly or biweekly call. A Level 5 case may be a new patient who is going to acute rehabilitation and needs discharge planning and family teaching, and will need home health.

The case managers do the acuity ratings on their own cases. The supervisor spot-checks as a quality control measure.

"We have identified the number of touches a patient with a particular condition needs based on our past experiences. That information is put into each level," Edwards says.

At the end of the week, the case managers complete their acuity reports and close any cases that are completed. They review the acuity report and change the levels of their cases if indicated. The final acuity report is sent to the supervisor, who enters it into a spreadsheet program designed in-house that takes into account the number and complexity of cases and comes out with an acuity rating for each case manager’s workload.

The information goes to the intake nurse so she can make sure she is assigning the new cases to the right case manager. The target is for each case manager’s caseload to have a weighted value of 200 or less.

New cases start out at Level 5 because the case managers have to complete an assessment and a care plan.

"It may not be a difficult case, but it’s assigned to Level 5 because it takes time to get a new case set up," Edwards says. The case may drop to a lower acuity level by the next week.

The case management department at BCBSOK handles catastrophic injuries and illnesses.

When a member has been in the hospital for seven days, his or her case is assigned to case managers who follow the hospitalization concurrently.

"We want case managers looking at the cases for identification of needs such as discharge planning and other resources," Edwards says.

Among the diagnoses that are triggered for case management are closed head injury, heart attack, stroke, amputation with a need for rehabilitation, traumatic brain injury, and some cancer diagnoses. Other triggers include frequent hospitalization, certain medications, cases that must meet certain criteria to provide medical necessity, and members who need hospice care.

"The cases that are triggered for case management are subject to change. We look at trends and changes in treatment regimes and change the triggers accordingly," Edwards says.

For instance, at one time everyone with HIV was assigned to case management. Now, because of newer medications that keep the disease under control and result in longer life spans, a diagnosis of HIV is no longer an automatic trigger.

The cases come from referrals by providers, self-referrals from members, referrals from customer service, and through precertification. Once a patient’s length of stay in the hospital has reached seven days, the case automatically is reviewed by case management.

The BCBSOK case management department has one supervisor and seven case managers, all of whom are certified case managers, except for one who is sitting for the exam this year.

Three nurse case managers coordinate the care for members in the Federal Employee Program. One nurse is an intake specialist who takes care of paperwork and required permission for case management and assigns members to the case managers.

The other three case managers are responsible for the other lines of business and are familiar with those contracts and benefit designs.

When a case comes into the case management queue, the intake nurse assigns it for concurrent review if the patient is in the hospital.

If a new case comes in over the telephone, the intake nurse does whatever is necessary to expedite the case. For instance, if the provider says the member needs intravenous antibiotics in the home setting, the intake nurse will get home infusion services started.

When a member is referred to case management, the case managers contact the member and the provider and complete a detailed assessment that can take as long as two hours.

They take into consideration the needs of patients at home, discharge planning needs while the patients are in the hospital, and whether the patients will need to be managed after discharge.

"There’s not just one recipe to determine who goes into case management. We look at a lot of different issues," Edwards says.

Sometimes the case manager may go through the entire three-page assessment form with the provider and the member and conclude that the member does not need active case management, she adds.

The case managers are generalists with a broad range of experience in hospice, home health, medical/surgical, and other areas of health care, and they all handle a variety of cases. The exception is one nurse with specialized training in organ transplantation who handles all the transplant cases.

Most of the case management work is done over the telephone, but when it’s necessary, case managers will meet with the member and family in person, either at the hospital or the home.

For instance, when a member has complex discharge needs, such as rehabilitation services, it is more effective for the case manager to meet with the hospital team during discharge planning, Edwards says.

In one instance, when the case manager felt the member was in danger from a caregiver, she met with adult protective services in the home and evaluated the situation.

Savings figured each month 

At the end of the month, each case manager figures the cost savings associated with her active cases. The case management supervisor enters the information from each case manager into a spreadsheet.

Among the savings they look at are those that result from a change in intensity of service; a change in the estimated length of stay for inpatient, outpatient, and home care services; savings from coming up with an alternative treatment plan that provides the same quality of care; savings from averted admissions; or a combination of factors.

For example, if a patient in the acute care hospital is medically stable and is moved to a skilled nursing facility (SNF), the case manager notes the difference in the daily rate for the acute care hospital vs. the SNF daily rate and calculates the savings.

Or a patient may be getting intravenous antibiotics in the skilled nursing facility and the case manager determines that the patient could go home with home health services. The case manager then calculates the difference in the cost of care.

The individual reports go to the supervisor, who separates out the cost savings by line of business as well as calculating the average cost savings per patient during that period of time.

The reports go to upper management as well as self-funded employee groups that contract with BCBSOK.