Case managers increase productivity and efficiency

Arkansas agency has holistic approach to care

An Arkansas home care agency director noticed many patients had a longer-than-necessary length of stay, partially due to problems with continuity in care.

"You could read the nursing notes and see that the patient was not getting a coordinated effort of care," says Rhonda Riley, RN, agency director of White River Medical Center Progressive Home Care, in Batesville, AR, a hospital-based agency with 40,000 yearly patient visits, serving north-central Arkansas through three offices.

Nurses made their own schedules. Referrals were given to whomever wanted another patient. In addition, nurses handled the scheduling of home health aides.

This system created too many inefficiencies, Riley says. For example, one nurse might drive from one end of the county to another within a day. Also, patients often had several different nurses within a week of receiving home care services.

Getting with the program

Riley and other managers decided to revamp the entire system, beginning with scheduling changes. They chose to use a case management model, with case managers coordinating care for all nurses.

The case management program worked. Between 1997 — when the program began — and January 1999, the program produced the following positive outcomes:

• Productivity increased. The amount of time spent on each visit decreased from two hours and 10 minutes per patient, which includes office paperwork time, to one hour.

• It’s now easier for the agency to reach physicians and gain their trust because the case managers are the only ones who call them.

• Length of stay decreased from about 71 visits per patient to 45 visits.

• Change helped the agency prepare for the interim payment system (IPS).

• Agency received high scores after a survey by the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations.

• Lowered staff mileage because scheduling is currently centralized.

Case managers are integral

It works because the agency’s four case managers serve as the central nervous system, directing care from a central location. They know what is happening with each case; therefore, coordinating care much more efficiently.

"The case manager is pulling out the clinical pathways each nurse needs," Riley says. "She’s pulling all this together, and the nurse is focusing on direct patient care."

Here is how the agency developed the program and achieved the positive outcomes:

1. Choose case managers.

Case managers have few patient duties, only making patient visits on rare occasions. Their main jobs include organizing and supervising.

Riley chose staff nurses who had good organizational skills, some of whom had been in supervisory positions before. "They had a good understanding of rules and regulations; they had a vision of what we were trying to achieve by coordination of care, cost effectiveness, and better care for our patients," she says.

The main office has two case managers, and the branch managers in the two branch offices also serve as case managers.

2. Cut paperwork for field nurses.

This helped to create staff buy-in. Before, field nurses spent a lot of their time in the office, handling paperwork. Now, there are fewer people in the office, and field nurses have less documentation to complete.

"The field nurses loved it. They got to spend more time and more concerted effort on the care of their patients," Riley says. "Productivity increased because nurses spend a longer time in patients’ homes, but less time in the office."

3. Create routines for case managers.

The case managers took over scheduling and the monthly task of checking billing against nursing notes.

Each month, case managers set up a patient list according to orders for the patient. As notes come in, the case manager reviews those that are completed and signed by the nurse, therapist, and aide. Each visit is highlighted as completed.

This makes monitoring frequencies and coordinating billing at the end of the month both efficient and easy. It also helps the agency verify there are no bills for visits, unless the notes have been turned in and the patient signed them. All notes are checked against the itineraries.

When new referrals are made, they are recorded and distributed to a case manager. The case manager assigns the admit visit to a nurse. The nurse completes the visit and reports to the case manager. The nurse and case manager discuss the plan of care and initiate care pathways. They also establish field charts and make referrals to other disciplines as necessary.

Also, case managers keep a notebook of Medicare 485 forms, new orders for each patient, and a case conference form. This keeps necessary information readily available for staff and physicians. (See case conference progress note, p. 19.)

Case managers have taken over the important task of contacting physicians and coordinating care with them. "There are some times when a nurse is in the home and needs to make that physician call immediately; otherwise, nurses can wait to come back into the office and talk to the case manager," Riley says.

This way, case managers have regular contact with physicians and office nurses all the time, and it’s easier to build a relationship. "Doctors trust them because they have one person to talk to; that’s another reason for increased productivity," Riley says.

When a physician returns a call to the agency, he or she is no longer told, "I don’t know the answer to that, because the nurse isn’t here right now." Instead, the case managers are always there to accept calls from physicians.

4. Divide case manager territory geographically.

It’s easier to use geographical areas because this ensures greater efficiency in scheduling patient visits, and it’s simpler, Riley says. When the agency receives a patient referral in Case Manager A’s territory, then Case Manager A takes over the care of the patient and assigns nurses to the case.

"This system cuts down on mileage travel because it is centralized, and everybody knows what everybody else is doing," Riley explains.

The system works well, says Brenda Rutherford, RN, a main office case manager.

"I manage patients in the north and west end; and the other case manager has the south and east," Rutherford explains. "I know a lot about her patients and where they live and vice versa; by looking at the board, I can see how to schedule somebody if I want to schedule one of her patients."

The case managers keep track of the schedule on an 11-inch by 17-inch work scheduler sheet that has columns for names, day of week, and time beginning and ending. (See sample scheduler sheet, above.)

5. Hold regular case conferences.

The agency holds case conferences every two or four weeks, depending on individual cases. The list is posted in advance, and the case conference form is kept with the managers at all times. Significant information regarding patients also is logged on the form.

Case conferences include discussions of completed patient goals, informing physicians of any changes and other information. Present staff members sign the case conference form and place it in the chart as part of the permanent record.

6. Have case managers meet regularly with nurses.

Case managers speak with nurses before an intake visit to give them specific details about the case and a general guideline of what frequency they should have, Rutherford says. "We go over the diagnosis and what some of these care paths recommend for frequency and duration," Rutherford says. "When nurses come back from the visit, they report to us."

Case managers hold one-on-one meetings in the morning when nurses come into the office to pick up their schedule.

"Sometimes we even have a line, and I’ve threatened to put up a number box," she says. "In the morning, we put out fires and get nurses out in the field, and we go through the day with some incoming questions from them," she adds. At the end of the day, case managers meet again with a nurse if the nurse has seen anything unusual in a case.


Rhonda Riley, RN, Agency Director, and Brenda Rutherford, RN, Case Manager, White River Medical Center Progressive Home Care, 1710 Harrison St., Batesville, AR 72501. Telephone: (870) 793-1480.