Best Practice Profile

First, develop a solid company philosophy

Correct caseload mix will follow

The American Health Consultants/Case Management Society of America 2000 Case Management Caseload Survey included responses from 62 case managers working for independent case management consulting companies. In this exclusive interview, Catherine M. Mullahy, RN, BS, CRRN, CCM, president of Options Unlimited, an independent case management company in Huntington, NY; 2001 national president of the Case Management Society of America (CMSA) in Little Rock, AR; and author of several popular books on case management, shares her own successful formula for managing case management caseloads.

Question: Practice setting analysis of data from the 2000 Case Management Caseload Survey found wide variation in caseloads based both on organizational structure and patient populations served. How would you describe Options Unlimited and its patient population?

Answer: We would be categorized as an independent health care and disability management company, with our core business being medical case management services. We provide these services on a national basis to client groups including employers, third-party administrators (TPAs), counties and municipalities, unions, the state in a Medicaid Model Waiver Program, managed care organizations, insurance companies and reinsurers, attorneys, and private individuals. At this time, our largest line of business is group medical.

In terms of demographics, because we work for the most part with employer-sponsored health plans, the populations we serve include all those individuals making up the employee group, as well as the dependents on their plan. This would incorporate everyone from infants through geriatric groups.

Further, the cases we work involve people cross-country, who live in metro areas, rural settings, and inner cities — locales that vary from densely populated areas with diverse resources to remote towns with minimal resources. The populations are culturally and economically diverse. We have managed cases for patients who spoke only Mandarin, Vietnamese, Korean, Spanish, and a host of other languages.

We work on behalf of individuals with private insurance and public insurance, via the Medicaid program, with plans that have very generous allocation of benefits, or within the same employer group, plans that have levels of benefits keyed to a range of employee-contribution levels. The Medicaid Model Waiver portion of our business is all pediatrics. Just like every other case management group, we often see high evidence of an unhealthy lifestyle after 45, with diabetes, cardiovascular disease, pulmonary problems, respiratory problems from smoking, and hypertension.

We’re seeing more people remaining in the work force beyond the age of 65, and the working "sandwich generation" with parents as dependents, so we’re seeing geriatric population groups, as well.

Question: The number of cases a case manager can manage appropriately is tied closely to the organization’s case management philosophy. How would you describe Options Unlimited’s case management philosophy?

Answer: Options Unlimited seeks to promote the best outcomes while ensuring cost-effective care: empowering and advocating for patients and their families, and facilitating services, seeking the best balance between optimum outcomes and use of care dollars in a collaborative effort with providers and payers, with the patient at the center of what we do. We help coordinate care in complex medical cases, and offer alternatives for high-quality care that often reduce costs and risk. Evaluating care options, we give families the information needed to make medical decisions, negotiate rates and discounts for services, and coordinate payment and claims filing. Options Unlimited monitors and facilitates care; the company never authorizes or certifies treatment or procedures. We are a resource for patients, physicians, providers, and payers.

Question: As part of its case management standards, URAC/The American Accreditation HealthCare Commission in Washington, DC, requires that case management organizations have a written policy regarding the setting of case management caseloads. What is Options Unlimited’s policy for setting caseloads for its case managers?

Answer: Each case manager will have a caseload that allows the cases to be worked to the extent of the need identified by the case manager. The needs and diagnoses of the cases, the case mix, the work style of the case manager, and the experience of the case manager together dictate how many cases each case manager can oversee. For example, a highly experienced case manager with strong expertise in oncology may have a lesser caseload because these cases are sometimes so intense. They often include organ transplants and chemotherapy and require a great deal of involvement by the case manager. On the other hand, a case manager may be able to carry a larger caseload of elder care cases. Elderly patients may have problems and needs, but the patients may be more stable over longer periods of time, are often less medically volatile, and treatment tends to be less aggressive.

What are the patient’s needs?

The patient also is taken into consideration when setting caseloads. What is the extent of the patient’s needs and resources? A patient with no family resources may place greater time demands on a case manager because now he is involved in setting up social support systems such as Meals on Wheels.

Our mission policy is to accept each case individually. Needs are determined, and a case manager is assigned to satisfy those needs. We watch caseloads to ensure that cases are worked appropriately — aggressively enough — so that we’re able to prevent problems and promote better outcomes.

Case management is a business, and case managers obviously have to be able to generate billable hours that reflect the hours they are being paid. We tell our professional staff they must be able to bill 36 hours a week. I give them room for professional development, conferences with their supervisors, etc. Further, not everything they do translates into a billable hour, or can be passed along to the client.

As a benchmark, we use as a frame of reference 25 to 30 cases per case manager. When I hear that some case managers carry 75 to 100 cases, I become concerned. What we call case management, and what the industry has defined as case management, no one can possibly do well with 75 to 100 cases.

I think each company, each department, each line of business sets its own definition for case management. What I have set as the standard for our company, and what I expect a case manager to do, may be very different from other companies.

Question: Nearly 30% of independent case managers responding to the 2000 Case Management Caseload Survey reported that new cases were assigned to case managers in their organizations based on the expertise of individual case managers, and 27% reported that cases were assigned based on geographic location. How are new cases assigned to case managers at Options Unlimited?

Answer: While we certainly do consider case manager expertise and geographic location, there is no hard-and-fast rule for assigning caseloads in our office. Perhaps one case manager has just been given two "heavy" cases (an organ transplant plus a high-risk pregnancy, or a stroke victim, or someone going home with deep wounds that need IV antibiotic, dressing supplies, and many ancillary services, etc.). Those two cases alone may occupy her for a full day. It doesn’t mean that every day those same two cases are going to need that same level of intervention. I keep in mind the needs of the cases. Every case manager has some that are fairly stable and some that are service-intensive.

With some acuity matters, the level of involvement required of the case manager has less to do with the clinical issues and more to do with the insurance and eligibility issues, the provisions in the plan that need to be addressed, the presence of a re-insurer, or a difficult, dysfunctional family situation. Without these circumstances, the patient may not be a problem to manage at all, but the extraneous matters can be obstacles that have an impact on the case manager’s ability to do her job.

Of the mix of 25 to 30 cases a case manager might have in our office, I would say that each case manager has three levels of cases. These are by no means split so that each measures one-third of her workload. She has very involved cases, stable but problematic cases, and cases where things are going along well, but need to be monitored over time to see the outcome, as experience has shown that this is the kind of case that needs continuing involvement. The smallest percentage of the caseload would be the very acute cases, with the larger portion being stable but problematic, and a small number needing little involvement, such as a stroke patient in rehab. The rehab is going to take some time, but that doesn’t mean the case manager should close the case. Rather, it means the case is less intense right now; it will increase again as the patient goes to the next level of care, such as bringing him home from the rehab facility.

When the patient was inpatient for four weeks, the case manager perhaps placed a weekly call to get reports, or to conduct a teleconference with the care team. Now, as the patient is ready to go home, the case manager’s involvement increases again. As a patient transitions from a place where all care is being provided to a community-based program, many questions arise: Do they need individual PT or OT? Can it be offered under one roof? Do people need to come to the home? Does the patient need transportation?

Maintain the balance

I feel it is vital that the caseload balance is right, or our case managers become overwhelmed and burn out. That would be disheartening for the case manager, and a loss to the patients and to my company.

Question: The 2000 Case Management Caseload Survey also found wide variation on how much time case managers in different practice settings spend on the six core components of the case management process identified in the CMSA Standards of Practice. How would you describe the components of your case management process and how much time is spent on each component?

Answer: It depends completely on the case the manager is working at the time. Sometimes, because of the complexity of the case, the greater portion of the time is spent assessing the patient’s needs to identify all the problems that must be addressed in the case management plan. In that case, a manager might not implement anything, but instead bring all the elements of the case into better focus. When we look at the core components of case management, assessing, planning, implementing, and coordinating would be the top activities, occupying the greater portion of a case manager’s time. Evaluating and monitoring require less time.

Again, this all depends on one’s philosophy of case management. If you just monitor things, it means someone else is "doing" and you’re not. Ours is a very action-oriented, front-line, make-it-happen, be-involved, uncover-the-problem case management. Assessing, planning, coordinating, and implementing, in some combination, take 75% of our case management time, with the remaining 25% occupied by monitoring and evaluating.

Many people use the term "monitoring" seemingly endlessly on reports. My feeling is, if you’ve been "monitoring" for the past six weeks and there’s been no change, you’re doing too much monitoring and not concerning yourself enough about "what’s happening, why isn’t it changing?" 

Question: More than 80% of independent case managers responding to the 2000 Case Management Caseload survey indicated that they reported "monthly" on the cases in their caseloads. How would you describe your reporting practices/policies?

Answer: Some case managers prepare reports for internal use only. If you’re a company whose services are being contracted for by a reinsurance carrier or a TPA, that entity wants to see what’s going on and what it costs.

As an independent case management company, we are often sending invoices with our reports, so not only do we need to document our services, but also keep our reports timely so that we are not burdening the payer with an overly lengthy report, with the accompanying large bill for service. If a case has occupied 10 hours, regardless of what our report says we have done, the fee attached to those hours will attract more attention than the patient’s progress, or savings on behalf of the client. I prefer to report (and bill) in smaller increments.

With our clients, we provide formal reports monthly, more often if the case warrants. In group medical, things move very quickly, or should be moving very quickly. For those group medical clients, progress reports on a monthly basis are advisable. If things are changing dramatically, we add an addendum after one or two weeks. If we wait too long, the news is old news, erasing or diminishing the opportunity to collaborate with the reader, whether it’s a reinsurance carrier or a client.

The reports are addressed to whoever is requesting the service. On cases that I believe will hit the individual specific limit of $50,000 or $100,000, I like to let reinsurers know there is a big case in the making, and that it is being managed. It helps them run their business and line of insurance better. It also establishes us as an entity unto ourselves and helps to bring new business to us.

We have case management initial evaluation and progress reports that provide the overview of the case findings, the clinical status, the course of treatment, the case management intervention, the problems identified, and the recommendations.

When a case closes, or every quarter, we prepare a cost-benefit analysis report. This is a financial business management report that provides the proof statement for case management — the "sell" for case management that answers the question, what did case management do on this case? What were the outcomes and savings? We define the outcomes — the clinical, behavioral, functional (personal, as well as job-related, function), emotional, and financial outcomes — and reports go to whoever is paying for our services and needs to know, at the end, what we did for them. All cost-benefit analysis reports are anonymous, with only a number and a diagnosis.

Question: How case managers work their caseload often is influenced by how their organizations measure the productivity of their case managers. How do you evaluate your own case managers?

Answer: In terms of productivity, we look at the results of the case manager’s intervention. Are people getting better? Are we reducing hospital admissions, length of stay, and complications? How many hours are they spending doing the work, and is it documented? Our supervisors meet with staff on a weekly basis, both one-on-one and in team meetings. A particularly difficult case might be staffed with several case managers and a supervisor to get a broader perspective on the case.

There is ongoing, documented feedback from supervisors to case managers. Written evaluations are given on an annual basis. Periodically, a supervisor will pull files and examine them for documentation. Each supervisor keeps track of her supervisory notes and whether suggested courses of action were pursued. We monitor our written patient satisfaction surveys. When a case closes, a supervisor now and then might call the family to ask them if all was handled to their satisfaction. We do not have an outside audit but do have several levels of quality assurance review, especially for new or off-site case managers, or if we have any reason to question or be concerned about the level of service.

Question: The technology and other resources available to case managers to help them perform their daily tasks greatly impact the number of cases they can handle efficiently. What resources do you provide to help your case managers manage their caseloads?

Answer: We have electronic documentation, and we require that our case managers be able to key in information and be on-line in the office. Some of our staff were hired before the advent of Windows and the Internet, and several have been brought kicking and screaming to the electronic horizon. At the same time, I am most interested in their case management skills. I need their nursing acumen; I don’t want to pay professionals to be typists. We provide our nurses with administrative staff for their lengthy reports and to help with correspondence, etc. We also have a clinical resource person who provides Internet-based research assistance to our case managers as needed.

[Editor’s note: As part of our ongoing commitment to help you increase your productivity and improve your outcomes, we would like to make the Best Practice Profile a regular feature of the newsletter. If you or your organization would like to share your caseload, staffing, or other case management administrative experiences with your peers, please contact Russ Underwood, managing editor, Case Management Advisor, at russ.underwood@ahcpub.com, or telephone (404) 262-5521. Please address correspondence for the author to cmullahy@optionsunlimited.org.]