Forget staffing formulas; it’s the case management model that matters

Get away from setting caseload targets, experts say

To decide how many and what kind of staff you need to optimize the efficiency of your case management department, you must look beyond simple caseload statistics and ask yourself exactly what you’re trying to achieve. Indeed, the many ways case management is defined at different institutions make it all but impossible to come up with a universal formula for assessing the staffing needs of a case management department, experts say.

"There are some general figures that consultants offer as to how many people you can case-manage. But when you look into it, you’ll find that it’s going to raise the question, what is case management?" says Patrice Spath, ART, a consultant on health care quality and resource management with Brown-Spath & Associates in Forest Grove, OR. "And you have to ask yourself, when consultants start throwing out numbers, what do they mean by it?"

Sharon Berkley, RN, case manager at Mercy Center for Healthcare in Aurora, IL, is grappling with those questions right now. She spent the last year and a half building the hospital’s case management program — implementing policies and procedures and helping develop the institution’s first few clinical pathways. She also designed the hospital’s three-tiered case management system, in which bedside staff manage the day-to-day aspects of a patient’s care.

"The bedside nurse should be able to look at the patient in a holistic manner and know what important resources need to be involved," says Berkley. "You don’t need a master’s-prepared nurse to know how to look at someone and know that they need nutritional support, for instance."

The second level of case management at Mercy concerns problem patients who require more in the way of discharge planning and financial analysis. "But the patient stays on the pathway and probably stays within the length of stay that’s appropriate for that patient population," Berkley says.

Berkley alone occupies the third level of case management at Mercy. She handles the most catastrophic cases, "the kind that explode into multisystem problems with multiple resources," she says. "And that’s what we’re looking at right now: to see who will man those forces. Will it be [more] case managers or clinical specialists or someone else? Will we have unit-based case managers or disease state management? Each hospital does it differently."

That, experts say, is the problem for case management directors trying to analyze their staffing needs. How helpful can staffing benchmarks for case management be, given the lack of consensus on how case management is conducted?

One preliminary step in deciding what your department needs in the way of staffing is to select a case management model that best suits the needs of your institution and your patient population, says Sue Esleck, MSN, RN, administrative leader, care continuum at Brookwood Medical Center in Birmingham, AL. "What I advise folks first of all is to determine what it is they want their case managers to do. Are you going to have just a pure clinical case management program, or are you going to integrate it with discharge planning, utilization review, and social services? Philosophically, that’s a conversation that has to be had," she says.

Another factor in deciding on a case management model is the opinion of the physicians you deal with. "If you already have very dynamic, assertive physicians who are accustomed to protocol-driven care, then the role of case manager is going to be different than if you’re in a facility or market where physicians really haven’t been challenged all that much in their practice patterns," Esleck says. "That certainly does lead to determining what your staffing and your numbers are like."

Four years ago, Brookwood’s case management system resembled the one now in place at Mercy, with separate departments for utilization review, discharge planning, and social services. Esleck pushed for a unification of those departments because of what she saw as fragmentation and role overlap among various professionals. In developing a new model for case management at the hospital, Esleck considered and then discarded the idea of having physician-based case managers.

The upside of the physician-based approach is that, because a case manager is working consistently with an individual physician, it’s easier to identify the physician’s practice pattern variations. "But the downside is, his practice pattern is your only point of reference," says Esleck. "In that situation, you have to be very familiar with established best practice, because otherwise you don’t have anything to compare him to. And a lot of facilities don’t even know what best practice is. I mean, they don’t know what current practice is in their facility, so how can they start to revise and standardize it to best practice?"

Another problem with the physician-based approach is the "subconscious tendency" to assign case managers to problem physicians, whose practice patterns tend to deviate from hospital norms. "So how do you prevent labeling physicians as ‘bad boys?’" Esleck asks.

Specialty-based approach proves inefficient

Instead, Brookwood went originally with a specialty-based case management model, in which case managers followed the patients assigned to them throughout the course of their care. The problem with that approach was that an individual case manager might have to shuttle between three or four different units during the course of a typical day.

"You’ve seen these case managers," Esleck says. "They’re out trucking along with an armful of reference materials and critical paths and insurance guidelines, and they have to spread all that out three or four times a day and log back into the patient information system on the unit so they can check the lab results and all that kind of jazz. It became an inefficient utilization of their time."

Last fall, Brookwood scrapped its specialty-based system in favor of a unit-based approach, in which case managers spend about 80% of their time on the unit to which they’ve been assigned. "That’s been very positive from an efficiency standpoint," Esleck says. "They’re on the unit when the physician makes rounds, so it’s very easy to stop what they’re doing, go with that physician, and immediately impact resource consumption right then."

Even so, Esleck hesitated before deciding to make the change. She was concerned that having case managers based exclusively on a single unit would blur the line between case manager and nurse. "Unless the nursing leadership in your organization really understands the role of the case manager, the case managers will suddenly be seen as part of that unit’s staff," Esleck says. "And because the work of taking care of these patients immediately must be done, the case manager can get pulled into special projects and that kind of stuff." Esleck adds, however, that because the case management department was already well-established at the hospital, she was confident that case managers would not be utilized inappropriately on the units.

Outcomes manager Bill Brodie, RN, heads up the case management efforts on Brookwood’s psychiatric unit. He is responsible for disseminating information to physicians and analyzing variable costs, and oversees three case managers with an average caseload of about 15 patients. The case managers monitor "the actual continuum of care, from admission all the way through discharge planning," Brodie says. This setup is similar in Brookwood’s other units, including cardiology and neurology, although caseloads vary, he says.

Originally, Esleck set a "ballpark caseload" of 18 to 20 patients per case manager, knowing that some programs like internal medicine would be comfortable at between 15 and 18, while programs like maternity could support 20 to 22 cases per manager.

But, Esleck cautions, "The pitfall and the lesson learned with staffing is not to get into a numbers situation for average caseload per case manager. We’ve found that the acuity of the patient varies so greatly, depending on specialty and type of program, that once you say ‘Oh, well, we would like to see the case load be X for the case managers,’ then everybody locks onto that number. Try to get away from setting those kinds of targets."

Support systems make a difference

Not only does patient acuity vary, but so do such factors as computer resources and effective support staff, Berkley adds. "A lot of it depends on what systems you have in place to expedite the case manager’s job," she says. "If you have policies and procedures in place so that her documents are clear and concise, so that she’s able to just go out and take care of the patient based on the pathway and standing orders, it’s a big help. If she has the necessary support system in place, it directly impacts how many patients she can actually take care of in a day." (See related story on support staff, p. 175.)

Rather than trying to come up with hard- and-fast numbers based on patient acuity, Esleck and her colleagues decided to develop a prioritization schedule that allowed case managers who felt overloaded to effectively prioritize the time they spent with patients. "Using that methodology, they could say, ‘I’m going to see all my new admissions, all my Medicares, and I’m going to make sure and see all my discharges. After that, I’ll see this patient over here who doesn’t necessarily have any urgent needs.’"

The prioritization tool, which Esleck currently is developing for publication, factors in such elements as the payer, the age of the patient, and the amount of family support. "It’s very specific, and we’ve actually put it into an exercise that we use during [patient] orientation."

Just as important as deciding how many to staff is the question of whom to staff, adds Berkley. "The type of person you hire has to be creative and innovative," she says. "Because it’s not just about following a clinical pathway. You need someone who can change and adapt, and who has a mind for business as well. When you’re thinking about staffing, the right person for that job becomes critical."

For more information on staffing case management departments, contact:

Sharon Berkley, RN, case manager, Mercy Center for Healthcare, 1325 N. Highland, Aurora, IL 60506. Telephone: (630) 859-2222.

Bill Brodie, RN, outcomes manager; Sue Esleck, MSN, RN, administrative leader, care continuum, Brookwood Medical Center, 2010 Brookwood Medical Center Dr., Birmingham, AL 35209. Telephone: (205) 877-1000.