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Caseloads are a primary factor in the quality of case management outcomes. Setting appropriate case management caseloads has always been a hotly debated issue. In December 2000, American Health Consultants in Atlanta, publisher of Case Management Advisor, and the Case Management Society of America (CMSA) in Little Rock, AR, conducted a national survey of case managers to help clarify some of the issues surrounding the caseload debate.
More than 520 case managers responded to the 2000 Case Management Caseload Survey. (For a breakdown of respondents by practice setting and a description of our methodology, see "CMs respond to national survey," in this issue.) Now that the results have been tabulated, Case Management Advisor has asked industry leaders to help decipher their significance.
When URAC in Washington, DC, added a caseload standard to the case management organization accreditation it launched in 1999, the caseload issue took on greater and more immediate significance. "URAC deliberately kept the standard broad," notes Catherine Mullahy, RN, CRRN, CCM, president-elect of the CMSA and president of Options Unlimited, a case management company in Huntington, NY. Mullahy served on the committee that developed the URAC case management standards.
"There are so many divergent practice settings, it is simply not possible to say for all organizations, This is the correct number of cases a case manager should manage,’" explains Mullahy. "What the standard requires is that case management organizations have a reasonable, established policy for setting case management caseloads that fit the organization’s practice setting and case management goals."
URAC drew attention to the caseload issue but did little to settle the questions being debated by the industry. Specifically, URAC’s case management standard does not answer the all-important question: How many active cases should case managers manage each month?
"It’s important that URAC thought caseload was important enough to include in their case management standards," notes Lesia C. Stuart, RN, BSN, CCM, a member of the national board of CMSA who helped develop the caseload survey tool. "I think many case managers had hoped that the URAC standard’s final language would set a magic caseload number."
Stuart adds, "They [members of URAC case management standards’ committee] discovered, as we did in the 2000 Case Management Caseload Survey, that there is no such thing as that magic caseload number that fits every case management organization. URAC placed its emphasis right where it belongs — on the importance of organizations developing a methodology to ensure quality when assigning case management caseloads."
When it comes to setting case management caseloads, the magic number lies somewhere between 16 and 75 active cases each month, according to the 2000 Case Management Caseload Survey. Specific findings include:
Finding that perfect caseload for case managers in your own organization depends on exactly how you define case management, as well as your case management goals, say industry leaders. "In addition to being a primary factor in the outcomes of case management, caseloads also are a measure of workload and productivity," says Sandra L. Lowery, RN, BSN, CRRN, CCM, president of CCMI Associates (formerly Consultants in Case Management Intervention) in Francestown, NH, and president of CMSA. "They can negatively impact outcomes if they are set too high and the cost of case management services if set too low."
Lowery explains that finding the appropriate case management caseload that optimizes both case manager productivity and case management outcomes depends on factors that include:
"We also intuitively know that the acuity of the population served will have an impact on the number of cases a case manager can effectively manage," says Lowery. "The relationship between the variables and the outcome is truly the only reliable way to demonstrate what functions are necessary for effective case management, which can the set the standard for an organization’s caseload determinations."
Mullahy stresses that setting case management caseloads begins with an organization’s philosophical approach to case management. "You cannot set case management caseloads without first defining exactly what case management is within your organization," she cautions.
"If your definition of case management includes working individually and collaboratively with at-risk patients and their families, monitoring patient progress, supporting the patient’s family, changing services when necessary, and working with financial intermediaries on behalf of your patient, then you are going to be able to handle fewer cases per month than another organization with a less comprehensive approach," Mullahy says, adding that her own case managers handle an average caseload of 25 to 30 cases per month.
Naturally, the number of cases a case manager can manage comfortably also depends largely on exactly how the case manager interacts with patients and providers, say experts. It’s simply common sense that a telephonic case manager will manage a larger monthly caseload than an on-site case manager.
It seems that even in this technological age, most case managers still have at least some face-to-face contact with patients and providers. (The survey also reveals that case managers face an alarming technology gap; see "Case managers face Web technology gap," in this issue.) Findings from the 2000 Case Management Caseload Survey include:
The resources case managers have access to and the tools available to them also affect the number of cases they can manage effectively, says Stuart, a case manager in Chattanooga, TN. "My own organization introduced a case management module to our information system in the 1990s with a goal of moving to a paperless documentation system, which we stepped in over a period of time." Stuart adds that she knows many case managers who continue to keep paper notes, even when their organizations have electronic documentation capabilities. "I know that in our own experience, we’ve found that our technical capabilities help our case managers effectively manage more cases."
The majority of case managers who responded to the 2000 Case Management Caseload Survey reported that they also use a combination of paper and electronic records. Specific findings include:
In addition to case manager/patient interaction, the severity or acuity of patients in an organization’s population must be weighed when setting caseloads, say experts. "For each individual case manager, we look at the mix between simple cases which are progressing smoothly and are expected to close without incident and more complex cases which require much more attention," says Stuart.
"The severity and types of conditions that end up in someone’s case mix are reviewed constantly in our organization," says Mullahy. "We look at each case manager’s case mix and allow the needs of the cases in that mix to dictate how many cases we assign each case manager. In a given month, one case manager may have 35 active cases, even though our average caseload is 25 to 30, because the cases themselves are stable and uncomplicated. Another case manager may only be carrying 20, but each case in that 20 is a complex case demanding special attention."
No matter what magic number your organization sets for its case management caseloads, care must be taken to assess whether that number is realistic and allows case managers to maintain quality standards, note experts.
"We review our case manager’s notes to make sure each case is progressing reasonably and that quality of care is being maintained," notes Mullahy. "If I don’t see movement in a case, I start to question whether the case manager is so overwhelmed by her caseload that she’s only doing crisis management rather than problem identification and resolution. One of the best contributions of case management is prevention of problems and promotion of better outcomes. You can’t do that if your work load is so high, all you have time for is plugging holes in the dike."
Patient satisfaction surveys also are a good indicator of whether your case management caseload is set appropriately, say Mullahy and Stuart. "We ask patients questions which include, How many times were you called by your case manager?’ and Were you called too frequently?’ If our patients are happy with our case management services, it’s likely that we have set an appropriate caseload," says Mullahy, adding that Options Unlimited also periodically speaks directly with patients as part of its own quality assurance effort.
"Patient satisfaction scores can provide an organization with useful feedback on its case management caseloads," agrees Stuart. "If the case manager’s caseload is too high, she may appear rushed when she speaks with patients on the phone, and that may negatively impact patient satisfaction scores."
In addition to patient satisfaction surveys, Stuart looks at her case managers’ individual quality audit scores to assess the appropriateness of case management caseloads. "We set quality standards for specific case management tasks. If a case manager’s caseload is too high, she may have difficulty meeting those standards."
As industry leaders continue to analyze the results of the 2000 Case Management Caseload Survey, they hope that the data help organizations promote both case manager productivity and desirable case management outcomes. "Analysis of this leading-edge data will open opportunities for insight into the range of caseloads currently being assigned in various practice settings," notes Jeanne Boling, MSN, CRRN, CDMS, CCM, executive director of CMSA. "The information and best practice benchmarks will be helpful to accrediting organizations such as URAC to assist in evaluating appropriate and best practice."
"The caseload survey data will provide comparative data relative to what others in the field are setting for caseload expectations," adds Lowery. "It will sensitize case management programs to consider the multiple variables that can affect productivity measurement, such as the travel factor involved in on-site and field case management, and electronic vs. paper documentation, and hopefully spur them to evaluate their current practice model relative to these variables."