CM staffing survey quantifies today's norms

By Richard Brandon, PE

With Karen Niemi and Debra Campbell, RN

Premier Inc.

Charlotte, NC

Richard Brandon, PE, is an associate with Premier, Inc.'s clinical operations improvement division. He is the consultant for Premier's North Carolina/South Carolina "collaborative workgroup" hospitals.

Karen Niemi is a senior associate with Premier's clinical and operations improvement division. She has extensive experience in case management and clinical consulting. She is the author of several care management/clinical pathway guidebooks.

Debra Campbell, RN, is an associate with Premier's clinical operations improvement division. She specializes in hospital and managed care management.

Case management is expensive. However, there is no question that effective clinical case management saves hospitals hundreds of thousands of dollars each year. How much should a hospital invest to set up and maintain a case management department? How many staff members is enough? How many is too many? A recent national survey conducted by Premier, Inc., was designed to answer some of these questions.

The goals of case management are related to both finances and quality of care. On one hand, case managers ensure that patients receive the most appropriate care in the most effective setting for the lowest overall cost. At the same time, they work with patients and their families to provide education and post-care follow-up.

But what size case management staff is needed for a hospital? Case management staffing is by far the largest cost associated with a program. Up to this point, case management staffing has been difficult to model and quantify.

In late 1997, consultants at Premier joined with six member health systems in an attempt to answer key productivity and staffing questions, such as:

· What are the current norms for case management program staffing?

· What is the average ratio of case managers to social workers?

· What is the average ratio of professional staff to support staff?

· How does our program measure against our peers?

To this end, Premier conducted a national survey of 36 hospitals and health systems, which was completed in February. The survey was based on Premier's recently developed case management program staffing model. Some of the more significant results are presented here for the first time.

The six member health systems participate in one of Premier's collaborative workgroups. Each system has agreed to collaborate on various operational issues in order to share comparative data, and research and develop operational processes. The members of the North Carolina/ South Carolina collaborative workgroup are: Cape Fear Valley Health System, Fayetteville, NC; Durham (NC) Regional Hospital; New Hanover Regional Medical Center, Wilmington, NC; Rex Healthcare, Raleigh, NC; Richland Memorial Hospital, Columbia, SC; and Roper CareAlliance, Charleston, SC. A Premier consultant works with all project teams in the group, effectively combining management engineering skills with the clinical experience of the team members.

The executive management staff of the six hospitals set up a case management project team. The chief operating officers asked this team to develop guidelines on case management program staffing to help them make informed decisions on future staffing requests and adjustments.

Team discovered void in literature

An initial literature search turned up little information on staffing studies or guidelines. "There truly is a void in the literature," says Fran King, director of case management at Richland Memorial Hospital and a member of the project team. "We could not find any type of formula that would help an organization calculate the number of staff needed based on the acuity of the patients."

The project team, made up of case management directors, had been developing indicators to measure case management staffing ratios. They decided to take this a step further and conduct a survey of Premier health systems. This would yield valuable information for the participating hospitals, and also help in formalizing the indicators that were in development. The team created the survey questionnaire and analyzed the subsequent data with guidance from consultants in Premier's clinical and operations improvement division.

"The survey demonstrated that most hospitals need to have clear methodologies for measuring the value or effectiveness of their case management programs," says King. "Right now we look at our average length of stay and avoidable days. But it's essential to develop other ways to measure our impact." The survey provides a first step in developing those new measuring tools.

The survey was designed to achieve three objectives. Its first goal was to determine the average case management staffing ratios, volumes, and patient intervention times from the data submitted by 36 hospitals and health systems across the country.

Premier's consultants then took each hospital's individual data and compared it with the averages of their peers for benchmarking purposes. Participants were able to see whether they were over or under the averages. Finally, the data were integral to a new case management staffing model developed by Premier. It provides a hospital with a quantifiable method - a formula based on national averages - to determine staffing requirements based on case volumes, patient acuity, and average length of stay.

With a first-ever survey such as this, one of the challenges was to develop definitions and specific language to analyze case management programs. The survey asked for staff to be segregated into four categories: management, case managers, social workers, and support staff. One question the team hoped to answer was: "What is the true `case management' portion of the staff's work?" To find the answer, participants were asked to segregate the staff's time into one of three categories: direct case management activities, indirect case management, or other activities (not case management-related).

Direct case management activities included everything pertaining to managing an individual patient's case, such as:

· screening of cases;

· patient management;

· coordination of care;

· clinical resource management;

· utilization review;

· discharge planning.

Indirect activities were more general and included activities that relate to all cases managed, including:

· committee time;

· departmental management;

· pathway development;

· scheduling patient tests;

· calling or faxing insurance companies.

On the survey, the case management director of each hospital was asked to estimate the percentage of their patients within five different intervention categories: extensive (significant case management involvement daily), moderate, low, minimal, and none (no case manager involvement needed for the patient). In addition, each respondent's case mix index was used to compare the amount of direct case management and social work intervention time by acuity levels.

Survey Results

As noted earlier, the survey results are based on data from 36 hospitals and health systems in 18 states, including California, Texas, Kentucky, Michigan, Massachusetts, North Carolina, and Florida. The sizes of the hospitals ranged from 5,000 to 40,000 annual admissions. The majority of respondent hospitals were in the range of 15,000 to 25,000 annual admissions.

When the survey was completed, the participants received a booklet of results from the analysis. The report also included a 10-page personalized staffing calculation for the participant's facility. It combined data from the hospital's patient volume, acuity, and average length of stay with norms from the survey.

The following is a summary of some significant results from the survey:

Management Span of Control

How many employees - case managers, social workers, and support staff - does the average manager of case management oversee? Our survey results indicated that the average span of control (the number of employees per manager) is 17.5 employees. Premier consultants agree that a range of 15 to 20 employees per manager is currently appropriate.

This statistic is valuable to assess the degree of management in the case management program. Too much management is an unnecessary expense. Too little management may indicate that the program is not being adequately supervised. Span of control can vary from a low of two or three for very intensively managed activities to 40 or more if the activities are very repetitive and require little management intervention.

Staffing Ratios

a) The Ratio of Case Managers to Social Workers

Many case management programs struggle with the question of the proper ratio of case managers to social workers. What percentage of the staff should be devoted to clinical needs, and what percentage to psychosocial needs?

The responses to this question had a wide range - from a 1:1 ratio (one case manager for each social worker) to a ratio of 7:1 (seven case managers for each social worker). However, the average for all respondents had a very strong concentration in the 1.8:1 to 2.4:1 range, or about two case managers for each social worker. More than half the respondents had values in the range of 1.5 to 3.0 case managers per social worker. An approximate benchmark is a 2:1 ratio, or two case managers for each social worker.

This information is useful for organizations that are close to a one-to-one ratio or lower (a higher ratio of social work than their peers), or a higher ratio such as 3:1 or 5:1 (heavy on case management, lighter on social work). Each hospital must determine what is appropriate for its needs, but a proper ratio is important to address the patient's clinical and psychosocial needs.

b) The Ratio of Case Managers and Social Workers to Support Staff Employees

The ratio of support staff (secretaries, clerks, and assistants) is equally important. What is the correct ratio of case managers and social workers to support staff?

Too much time spent on clerical activities

The survey found an average ratio of 10:1, or 10 case managers and social workers for each support staff person. Premier's managed care consultants judge this ratio to be too high to effectively utilize each position's strengths. With a ratio of 10:1, case managers often are required to perform clerical duties such as faxing referrals, entering data, and answering telephones. With a slightly lower ratio (more support staff), case managers and social workers can spend more time on direct patient activities that result in clinical expense savings.

This ratio also is dependent on the procedures and methods in a department. For example, if a department uses a great deal of manual tasks (no electronic data interchange and very few computerized databases), the department's support staff requirements will be greater.

Volume Ratio

Another measurement the team looked at was the annual "managed cases" per case manager or case management FTE (full-time equivalent). Managed cases refers to only those cases that are "managed" by the case management staff. This usually makes up 50% to 70% of a hospital's inpatient caseload. This "managed case" volume was then divided by the number of case management FTEs to arrive at the ratio.

The survey norm for this ratio was approximately 900 annual managed cases per case manager. The measure is not sensitive to patient acuity levels. It is a pure measure of volume per case manager only. This measure, used in conjunction with other key data, can assist hospitals in estimating the number of case managers needed to staff the department.

Intervention Time with Patients

Intervention time is a very important indicator - one not currently being tracked at most hospitals. Having reliable intervention data for different levels of acuity allows a department to assess its productivity, and to evaluate its methods compared to others. How much time do case managers and social workers spend with the average patient each day? As acuity increases, does the time per patient per day also increase?

To obtain these numbers, Premier's case management consultants developed an average case manager contact time for each of five patient categories (extensive, moderate, low, minimal, and none). For example, in the moderate patient category, the direct case management contact time is 30 to 60 minutes per day. An average time of 45 minutes was used as a point estimate.

Each hospital listed the percentage of its patients who met the criteria for each category. With this data, an average intervention time per patient could be calculated. Hospitals with a higher percentage of extensive and moderate patients consequently had a higher minutes per patient per day value. The same type of calculation was used for social work minutes per patient per day.

a) Case Management Minutes per Patient per Day

The survey indicated an overall average of 35 minutes per patient per day for case managers. This reflects time spent on direct case management activities such as coordination of care, discharge planning, negotiation for services, clinical resource management, evaluating the care process, utilization review, and screening of cases.

However, Premier's consultants regard this survey average as inflated, and the actual intervention time is significantly less than the survey average. Some of the error may be attributed to the survey method used. Given that this is a key indicator, additional data will be collected on future surveys and project work.

b) Social Work Minutes per Patient per Day

The ability to assess average social work time with a patient is critical. This indicator reflects time spent on direct patient activities such as discharge planning, placement assistance, psychosocial counseling, crisis intervention, guardianship issues, adoptions, financial assistance, and abuse/neglect cases. It does not include indirect activities such as education committees, professional development, team and service line meetings, data collection and analysis, and clinical pathway coordination.

The survey resulted in an average of 40 minutes per patient per day. As with the case management indicator, Premier's consultants judge this average also to be too high. Additional data will be collected on this indicator.

c) Does Intervention Time Increase as Acuity Increases?

The survey also sought to determine whether there was a correlation between intervention time and acuity. We used case mix index (CMI) as an acuity index because it is generally considered a reliable indicator of acuity levels. All survey data were summarized according to CMI ranges and then plotted graphically. (See average case manager minutes/patient/day vs. CMI and average social work minutes/patient/day vs. CMI, p. 156.)

CMs devote more time to acutely ill patients

For case management, the graph shows a slight upward trend. As the CMI went up (the patients in a hospital are more acutely ill), the case manager intervention time also increased. This tends to indicate a direct relationship: More acutely ill patients are receiving more case management intervention time.

Organizational Structure

When we began the study, the case management team had two expectations:

· About 60% of all case management staffs would be located in a centralized department within the hospital.

· There might be a trend toward more bedside case management (case managers that are not in a centralized department).

In fact, the survey found that 92% of staff were located in a centralized department, with only 8% decentralized. Centralizing staff within a case management department appears to be the choice of most hospitals, while case management by bedside nurses was not widely practiced by the survey participants.

Conclusions and Next Steps

Case management has grown rapidly since the late 1970s. It is estimated that 50% of today's hospitals have a formal case management program. Others are being formed daily.

Case management has been implemented quickly in order to help control clinical costs, but also with an eye toward balancing staff with responsibilities. Up to this point, each hospital operated independently to determine whether its staffing was in balance or not.

As we approach a new phase in case management, we are beginning to assess the cost/benefit of these programs. Within a particular hospital, what expenses are necessary to set up a case management program, and what dollar savings should be expected? This first-ever survey on staffing provides a significant start to assessing the larger model. Using both clinical experience and management engineering tools, this project team has established that it is indeed possible to measure and benchmark the case management staff in a quantifiable way. We now have initial data to begin to answer administrators' questions about what range of staffing is needed for a particular case volume and what ratios of staff types are prevalent.

This survey is only the beginning, however. Premier's Clinical and Operations Improvement group has plans to refine these staffing ratios with a follow-up survey and to include more in-depth questions and a broader focus. For example, future versions of the survey will:

· Identify the economic and outcomes impact of case management activities.

· Attempt to develop an economic value unit in order to measure a department's success.

· Seek to identify the best practice case management staff in terms of size, skill mix, and outcomes.

· Clarify patient intervention times to include specific activities.

· Specify indirect patient care activities such as calling physicians, calling insurance companies, scheduling X-rays, etc.

· Recognize the role of new, emergent case management staffs, such as emergency department case managers, community-based case managers, and disease-specific, chronic care patient case managers.

For more information on Premier's case management staffing model, contact Karen Niemi at (704) 679-5356.