Are you tired, overworked? You must be a case manager
Make the case for fewer tasks, more staff
It’s been happening for years. The Centers for Medicare & Medicaid Services (CMS) or commercial payers start a new program or ask for additional information and the responsibility is delegated to case management "since they’re in the charts anyway." As a result, many case managers are feeling overworked and often can’t do their jobs adequately.
Over the years, the caseloads carried by case managers haven’t changed, but hospitals have been adding other pieces to the case management workload, says Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, and partner and consultant in Dallas-based Case Management Concepts. "In order to keep adding more tasks to case management duties, the case manager-patient ratios have got to get smaller. Case management leaders can’t keep agreeing to take on more responsibilities. Instead, they should say they can’t take on a certain function and suggest a way to cover it," she says.
Case management directors need to make sure that case managers are not so overloaded they can’t do their job, says Teresa C. Fugate, RN, BBA, CCM, CPHQ, a case management consultant based in Knoxville, TN. The problem is that most of the time, case management is thought of as a cost center and not a revenue center, Fugate points out. Administrators don’t understand that case management and care coordination are part of the revenue stream, even though the hospital loses revenue if case management tasks aren’t done well, she says.
"If hospitals continue to pile task after task on case managers and they carry a heavy caseload, they will fall short because they can’t do everything and do it well. When hospitals keep adding things onto case management without determining that the activities are appropriate for case managers, they are setting themselves up for failure," Fugate says.
At the same time case managers face challenges in getting the job done, there are tremendous opportunities for case managers as healthcare changes and Medicare and other payers add more requirements and hospitals look for ways to meet them, Cesta points out.
"Case managers are in a unique position. We are becoming the pivot point for a lot of new things. If there was ever an opportunity to demonstrate the value of case management, it’s now," Cesta says.
"With the changes in reimbursement, hospitals are seeking opportunities to become more efficient and decrease the potential for poor reimbursement. Decision-makers and leadership are becoming more open to looking at how best case managers can accomplish their jobs," says BK Kizziar, RNC, CCM, CLCP, a case management consultant based in Southlake, TX.
In order to get more staff, case management directors need to be able to show the value the department brings to the organization to the senior leadership, which always has so many competing priorities, says Denise Majeski, MSN, RN, ACM, NE-BC, interim chief nurse executive at Northwestern-Lake Forest Hospital, a 201-bed community hospital in Lake Forest, IL, that is part of Northwestern Medical System.
"Hospital management and staff outside the case management department often do not understand the function of case management and the value it brings to the organization. To do so, you need to be able to show what case management does, what the outcomes are, and show the value of adding additional staff. If you don’t have a model, a workflow process, and metrics, you won’t be successful in proving your value," she adds.
Case managers have not been adept at educating the hospital administration on case management activities and how they affect the bottom line, Fugate says. "Increasing staff is all about revenue. If you can’t prove that you can impact the quality of care, length of stay, and readmissions, you aren’t going to be able to convince management that you need additional staffing," she says.
Case management leaders must market their department’s services to leadership, Fugate says. "In this environment, increasing case management staff is going to be a hard sell," Fugate says. For instance, a hospital’s loss of money in the CMS readmission reduction program may not be as much as the cost of developing a program to follow patients after discharge, she adds.
On the other hand, when lengths of stay are three to five days at maximum, there are some critical activities that must be done, she adds. "Show where your successes are in reducing length of stay and where failures, such as readmissions, are and include the activities involved and the time it takes to do them. It still will be a hard sell," she says.
Solutions that may be more financially viable than adding more case managers include developing specialty positions that optimize the skill sets for staff, hiring clerical support to handle all the case management tasks that don’t require a license, or investing in case management software, Cesta says. "If you go to the administration with a business plan that calls for a ratio of 1 case manager for every 10 patients, the average hospital administrator won’t go for that. But if you ask for one specialty position focused on readmissions or three clerical jobs, you may be successful," she says.
For instance, your hospital may have only a few readmissions at a time. That may make it cost-effective to add a readmission reduction or transition case manager who focuses on the problem hospitalwide, she suggests.
"Our hospital has a person who follows at-risk patients for six weeks after discharge. It’s remarkable how many problems she has caught and solved," she says.
Another add-on position is a discharge planning specialist who handles complex, time-consuming cases, such as those that involve setting up a guardianship, or finding placement for an undocumented person. "This person could carry a caseload of complex patients and free other staff to manage and move the other 80% of patients through the continuum," Cesta says.
People in a specialty position develop the expertise to perform their job quickly and efficiently, especially when it comes to complex case management, Cesta says. For instance, if a case manager encounters the need to set up a guardianship only once or twice a year, he or she can’t do it as quickly as someone who deals with it on a daily basis. "The specialty case manager has the connections and knowledge to do the job, and that can make a huge difference," she says.
Some hospitals have set up resource management centers staffed by clerks and/or LPNs who coordinate referrals and arrange for resources such as home health and social services, Fugate adds.
Make sure that the case management department handles only tasks that are specific to the job description and practice standards of case management, Kizziar says. "When hospitals don’t know where to send a responsibility, they are notorious for sending it to case management. Case managers are doing legacy tasks that they have accepted over the years. This has to stop. It significantly limits case managers’ ability to be successful when they have responsibility for non-case management duties," she says.
The case management role should include partnering with physicians, managing the cost of care and length of stay, care transitions, and preplanning of transitions to the next level of care, she says.
"I still go to hospitals where case managers do utilization review and social workers are in charge of discharge planning. This worked in the 1980s, but it isn’t the best way to do it now. Utilization review is not a unique function of case managers," Kizziar says.
She recommends that hospitals take the utilization review role away from case managers, freeing them up to sit down with patients and families to get the information they need to develop a care plan, and manage the transition to the next level of care.
When the case management team includes the case manager, social worker, and utilization review nurse along with clerical support, the case manager can handle a larger caseload than the case manager who has to do all of those things for each patient, Kizziar says.
It works best for appeals and clinical documentation improvement to be removed from the day-to-day work of case managers, Cesta says. "I see a lot of value in parsing it out. Case managers can’t do this and their regular tasks such as care coordination and discharge planning. This is a good place for other specialty positions," she says.
Case managers get a lot of requests to review denials that are not clinical in nature, Kizziar adds. "These need to be handled in another department. In addition, clinical denials don’t necessarily have to be handled by case managers. They can be handled by nurse auditors, particularly if there is an electronic medical record," she says.
- Toni Cesta, RN, PhD, FAAN, Senior Vice President, Operational Efficiency and Capacity Management at Lutheran Medical Center, Brooklyn, NY. email: firstname.lastname@example.org.
- Teresa C. Fugate, RN, BBA, CCM, CPHQ, Case Management Consultant, Knoxville, TN. email: email@example.com.
- B.K. Kizziar, RN-BC, CCM, CLP, Owner of B.K. & Associates, Southlake, TX. email:firstname.lastname@example.org.
- Denise Majeski, MSN, RN ACM NE-BC, interim chief nurse executive at Northwestern-Lake Forest Hospital, Lake Forest, IL.email:Dmajeski@lfh.org.
- Jenny Prescia, MSN, RN, ACM, CCDS, interim director of case management for Northwestern-Lake Forest Hospital, Lake Forest,IL. email:email@example.com.