Case Management Insider
The customization of best standards for practice models
More on case management roles, functions, models, and caseloads - Part 4
By Toni Cesta, PhD, RN, FAAN
Senior Vice President
Lutheran Medical Center
Brooklyn, NY
In this month's issue of Case Management Insider, we will continue our discussion on case management roles, functions, and models, with more information on today's best practice models. We will explore the advantages of each model and minimum staffing ratios for each.
As we have learned, there might not be one generic model for every organization; however there are basic core roles and functions that should apply to any contemporary case management model. The customization comes after those core roles have been determined, and the functions for each have been established. It is important that each hospital develop the additional roles and/or functions that they might need to meet the organization's outcomes. All of this should be done within the case management standards of practice as we have discussed.
Advantages of each model
The integrated and collaborative models have their own advantages, as well as disadvantages. As we reviewed last month, the disadvantages have to be carefully weighed. In addition to weighing the disadvantages, the advantages also should be weighed and considered. This process should be done using a steering committee to work through the decision-making process. Weigh each advantage and disadvantage against the goals of the particular organization. By involving a committee of individuals from a variety of departments and disciplines, the case management department will have a greater chance of success as the model is rolled out.
The integrated and the collaborative models build on the inter-relationships of the social worker and nurse case manager to enhance the case management outcomes. Neither model can be successful without strong social work involvement.
The importance of adequate staffing
By Toni Cesta, PhD, RN, FAAN
Senior Vice President
Lutheran Medical Center
Brooklyn, NY
No practice model, no matter how carefully designed, will be successful if it is not adequately staffed. Other disciplines and specialties have been able to determine adequate staffing ratios. Bedside nursing, physical therapy, and even house staff, have predetermined caseloads. Case management has lagged in the establishment of such caseloads, and hospitals have been slow to adopt newly established caseloads and budget for them appropriately.
Because of this problem, many case management departments still function with inadequate or severely inadequate caseloads. When this happens, the case management department finds itself in a position of selecting only those functions that must be done, such as clinical reviews or discharge planning. All other activities, such as care coordination and facilitation, cannot be completed.
When a case management department gets into this kind of position, staff members become dissatisfied with their work, work becomes task-oriented, and ultimately the department no longer performs true case management.
Models are the foundation of the department, and staffing ratios are an important part of any model. The integrated and collaborative practice models are alike in that they require the following to be successful:
- adequate staffing;
- balanced workload;
- skilled staff;
- strong leadership.
The roles, function, and caseloads of any models are interrelated. The more roles and functions you give a case manager or social worker, the fewer patients he or she can handle. This point might seem obvious, but not necessarily so.
Issues that impact caseloads
By Toni Cesta, PhD, RN, FAAN
Senior Vice President
Lutheran Medical Center
Brooklyn, NY
Like any model of care delivery, there are a variety of elements that impact on case manager or social worker staff-to-patient ratios. They are as follows:
Model design. The first, and possibly most important, element affecting the need for specific staffing ratios is the model in use. The integrated model requires somewhat different ratios from the collaborative model, and these basic ratios should be carefully considered. However, these ratios should not be considered in isolation of the other elements we will now review.
Roles and functions for each discipline. As the model is selected, the specific roles and functions must be aligned with the selected model. The most common roles assigned to case managers and social workers today include the following:
- patient flow – coordination and facilitation of care;
- utilization and resource management;
- denial management;
- variance tracking;
- transitional and discharge planning;
- quality management;
- psychosocial assessments and interventions.
These roles are foundational to both models and, thus, should be included. More variation can occur when looking at the functions subsumed under each role. By delimiting the number of functions under each role, and/or dividing them between the social worker and case manager, there can be a better balance between the roles and functions for each member of the team.
Patient assignments. The assignment of patients is another key component of the overall model for the case management department. Below are the most common variations in terms of patient assignments:
- unit-based;
- disease-aligned;
- product line;
- physician-aligned;
- high-risk criteria;
- payer;
- complexity;
- length of stay;
- cost;
- clinical;
- hybrid.
The most commonly seen patient assignment structure is unit-based. In this approach, the case managers and social workers are assigned to specific nursing units. Depending on the size of the unit, this structure might mean more than one unit, or part of one unit. The advantages of this approach include the fact that the case manager and social worker become part of the staff on that unit. In addition, they are physically present on the unit thoughtout the day and are available to other team members, particularly the physicians, as they come and go from the unit.
The other approaches should be carefully considered because even if you select a disease-based or physician-aligned approach, you still will need to have some other way to assign patients who are not within those specific disease groups or who are not assigned to those specific physicians or hospitalists.
The physician — or disease-aligned assignments. These allow for continuity of care and, therefore, are appealing to some hospitals. In those circumstances, another approach will need to be used for those patients who fall outside those pre-determined assignments. These models become a hybrid, incorporating more than one patient assignment approach.
No one approach is perfect and all need some amount of modification to make them work for the specific hospital. The selection of the patient assignments also will play a part in the determination of the final staffing ratios.
Payer mix. As you consider your staffing ratios, you also should analyze your hospital's payer mix. The percentages of each payer can have an impact on the type and amount of functions the case managers and social workers will need to perform, and they might result in the need to adjust the ratios in some way. For example, if the hospital is in a highly managed care environment, this situation might mean that a greater number of clinical reviews need to be done. The number of clinical reviews will impact on the workload of the nurse case managers.
Conversely, if the hospital has a high percentage of Medicare patients, then this situation might mean more complex and/or time-consuming discharge planning. Ratios might need to be adjusted accordingly.
A high percentage of Medicaid patients might mean that the patient population has a greater number of psychosocial and/or financial issues. High Medicaid hospitals might need a greater proportion of social workers.
Intensity of services provided. Intensity of services has to do with the types of clinical services the hospital provides. Is the hospital a trauma center? Does it perform complex surgeries such as brain, open heart, or transplants? Is the hospital a community or tertiary hospital? Are you typically transferring more patients into or out of the hospital?
The intensity of the services provided can affect the degree of complexity associated with the coordination and facilitation of care performed by the case managers. It will also have an impact on the length of stay.
Complexity of patients served. Patient complexity is a phenomenon specific to every hospital. It can have an affect on the workload of the case manager and social worker. It usually will align with the payer mix, but not always. The patient population might have a higher degree of complexity associated with clinical issues. Conversely, the complexity might lie with complexity of psychosocial issues or financial issues. Each of these elements will have an impact on the role of the case manager and social worker in different ways.
Length of stay. The element of length of stay can have an impact on case management if it is longer or shorter. What does this statement mean? Shorter lengths of stay mean that there is quicker turnover of patients. This length of stay results in more admissions and new assessments for the case manager. It also might mean more referrals to social work. Conversely, longer lengths of stay might be a result of one of two things. It might be because of the severity of illness of the patients treated, or it might be because of complex discharge planning issues. It could also be a combination of these. Because of the variety of issues surrounding length of stay, it should be considered, but not to the same extent as some of the other elements.
Use of technology. The use of case management software can have an impact on the flow of work for the department by eliminating some of the paperwork and helping to make the professional staff more efficient. More case management departments are obtaining specialized case management software. This software includes workflow tools and an electronic way to perform clinical reviews and discharge planning functions. The more automated the department, the more effective the staff can be in performing their routine daily work.
The department always should have some clerical staff to support the work of the professional staff. Faxing, copying, or ordering durable medical equipment should be done by the support staff, also freeing up the professional staff to perform their key functions.
Technology might not ultimately alter the professional staff's ratios, but it will allow the staff to function at a higher level and will increase the likelihood of professional job satisfaction, as well as the achievement of the department's expected outcomes.
The process of staffing analysis
By Toni Cesta, PhD, RN, FAAN
Senior Vice President
Lutheran Medical Center
Brooklyn, NY
In this month's Case Management Insider, we have reviewed the elements that might impact on the staffing ratios of a case management department. Each element should become part of an analysis process that can be used to customize the ratios to a specific hospital.
The first step is to start with the baseline staffing ratios recommended within each model. They are as follows:
• Best practice caseloads in the integrated model:
— RN Case Manager
o 15 patients/beds on medical floor
o 20 patient/beds on surgical floor, ICU, Acute rehabilitation
o 20-30 patients/beds on Pediatrics, OB/GYN
— Social Worker
o 17 patients (active cases)
— Emergency Department Case Manager
o Depends on patient care needs on any given day
• Best practice caseloads in the collaborative model
— RN Case Manager
o 15-23 patients/beds on medical floor, surgical floor, ICU, Acute Rehabilitation, Pediatrics, OB/GYN
— Social Worker
o 17 patients (active cases)
— Business Specialist
o 20-40 patients
— Emergency Department Case Manager
o Depends on patient care needs on any given day
The most significant difference in the staffing ratios between the two models is that in the Collaborative Model, there is the addition of the business specialist. This difference adds another position to the model and therefore the staffing ratios need to be adjusted accordingly.
Once the model has been selected, the ratios can be determined from the tables above. The next step would be to take the indicators and use them to determine whether the baseline ratios need to be increased or decreased. (To review the indicators, see article, above.)
As you proceed through this process, consider the clinical areas you are seeking to staff, as the ratios will need to be further refined to those specific areas as well.
Vacancy coverage
Most case management departments still do not budget for vacancy coverage. Vacancy coverage refers to the additional positions that are needed to cover assignments when staff is off for vacation, holiday, sick days, etc. Some departments might use per diem staff to fill in these gaps. However, "float" staff is more economical and more reliable as they are budgeted positions available to be plugged in wherever needed.
Early case management models could get by without these additional positions as the work was less complex and less time dependent. In today's contemporary environment and with today's best practice models, vacancies cannot be left open. Staff cannot double up on assignments and still get their work accomplished. Like any clinical department, case management should be staffed for these expected absences so that the work can be accomplished and goals can be met.
Moving forward
Adequate staffing means a balanced workload for all staff. Without it, staff will constantly feel as if they are simply "putting out fires" every day. Staffing ratios in case management are probably the least understood, but they are the most important element of any department. If you are having trouble meeting the goals within your department, step back and take a look at your staffing, including the patient ratios, as well as the mix of social workers and nurse case managers. Also look at the other resources in the department, including clerical support staff, technology, and vacancy coverage. Each and every one of these elements can make or break a case management department. Add to that the need to have talented staff and strong leadership and you have the recipe for success!
The staffing ratios should never be considered stagnant, but they should be reviewed annually. Take time to review the elements provided here so that your department can remain a productive and vital part of the care delivery system where you work.
Remember that the ratios for best practice have been tested and retested. Every department needs to have benchmarks that determine how the department should be staffed and the work should be organized. Case management is no different!
In this month's issue of Case Management Insider, we will continue our discussion on case management roles, functions, and models, with more information on today's best practice models. We will explore the advantages of each model and minimum staffing ratios for each.Subscribe Now for Access
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