Assign cases based on acuity level of patients, not just on the number

Managing some cases takes a few minutes; others take hours

If one case manager oversees the care of 20 patients in a day and another handles only 18 cases, the first case manager must be more productive, right?

Not necessarily, asserts Teresa C. Fugate, RN, BBA, CPHQ, CCM, manager of Pershing, Yoakley & Associates, a Knoxville, TN-based health care consulting firm.

"It’s not comparing apples to apples. One individual patient could take 15 minutes, and another could take two hours, depending on the number of functions the case manager may perform with a given patient," she says.

In some cases, 20 patients could take only five hours in a day, while 18 patients could take 16 hours, she adds.

That’s why Fugate advocates a system in which case managers are assigned cases based on how long each is expected to take, rather than just dividing up the number of cases on a particular unit.

She recommends that hospital case management departments define the activities required by case managers and perform time studies to determine the estimated time it takes to handle various case management activities. Once the manager has a good idea of the time involved in handling each activity, he or she can base assignments on the expected length of time for each case.

Switching to an acuity-based system for case management assignments can result in big benefits for your case management department, Fugate says.

Not only will it help spread out the workload evenly, it is a good way to measure the productivity of your staff and justify to management the need to increase or reduce staffing, she adds.

For example, one hospital case management department was able to show the need for three new case manager positions at a time when other departments were being asked to cut staff.

"First, they were able to show the benefit of case management, how they were reducing the denials and making sure the hospital was compliant with regulations," Fugate says. "However, there was only so much time in the day to perform the required functions, and areas of risk were being overlooked. Using an acuity-based system, the manager was able to justify the need for three new staff."

By compiling the amount of time case managers were spending doing clerical jobs, such as faxing and sending out letters, the case management department saw the benefit in hiring two clerical people instead of filling one of the case management positions it had open, redesigning the activities, and freeing up the case managers to work with patients.

"Copying or faxing is a clerical activity, not a professional activity. It’s ridiculous to pay professionals to do nonprofessional jobs," she adds.

At another facility, data collected helped the administration realize how much time case managers were spending on hold during phone calls to provide clinical information to commercial payers. By redesigning the process and activities performed, the department set it up so a clerical person who does data entry can hold for the case manager. Case managers carry walkie-talkies and are notified when the call comes in.

"The case managers are able to utilize their time more efficiently to intervene with physicians or perform quality reviews instead of tying up a line on the nursing unit and having their time wasted on hold," she says.

Haywood Regional Medical Center in Clyde, NC, has been using an acuity-based system for case assignments for more than five years and is pleased with the results, says Shirley Trantham, RN, BSN, CCM, director of health resource services in the case management department at the 200-bed hospital.

The hospital has seven case managers, one of whom spends half her time on infection control activities. Two social workers handle placements and psychosocial problems and fill in when the case managers are overloaded.

Trantham initially started measuring acuity as a way of showing the need for more case managers in her department. Her case management staff has increased by 2.5 full-time equivalent positions since she started measuring acuity.

How the system works

Here’s how Haywood’s acuity system works:

The case management department receives a worksheet each morning for new patients admitted in the past 24 hours. The case manager who handles the particular unit to which each patient is assigned reviews the worksheet and uses a guide to determine approximately how much time he or she can expect to spend with the patient.

"We know if the patient has a high-risk diagnosis or if the patient is on a pathway, it will take longer than other patients. The case managers do education for the high-risk patients, discharge planning, quality review, utilization review, and utilization management. They take all of that into consideration," Trantham says.

The case managers write the amount of time they expect to spend on each patient on a board in the case management department and enter it into a log book.

Trantham looks at who has the biggest caseload and determines if she should switch patients from one case manager to another or if she needs to assist in taking care of the patients.

The information on the board does not contain patient names, only the case manager’s name, the unit, and the number of hours.

The honor system works extremely well, she says. "The staff are more likely to assign too little acuity to the patients rather than too much time. Somehow, it all works out. They may overshoot on one patient, but something they didn’t anticipate on another case adds an extra hour."

By lunch, Trantham and her staff have a good idea whether the work is going as planned and can make adjustments.

The case managers also note their nonpatient hours, such as going to meetings.

Trantham periodically goes through the information in the log book to come up with productivity measures for the department and each case manager.

The flaw in assigning patients by census is that it doesn’t account for the amount of time involved in a particular patient’s case, Fugate says.

A case manager who is struggling to take care of the needs of several complicated patients during the day may not have time to do chart reviews of her other patients and may miss physician orders, such as an order to discharge the patient if a chest X-ray is clear. In that case, a patient may remain in the hospital for another day and may no longer meet the insurer’s medical necessity criteria, resulting in a denial of authorization for the continued stay.

Assigning case managers on an acuity basis can’t take care of every problem that is likely to arise, but it can help, Fugate says.

Census-based assignments usually do not allow for adequate cross-coverage for staff and offer no accountability for case managers to assist overburdened colleagues.

If a case manager finishes the cases she is assigned, under a census-based system, she may go home instead of assisting those who have complicated cases or, if she does offer assistance, the offer may be too late to prevent a delay in service, Fugate says.

"Under a census-based system, what people don’t realize is that they may be short of staff, but there’s no way to prove it because there is no way to measure true productivity," she adds.