How do we determine standards for case manager caseloads?

One of the most common questions I receive from fellow case managers is: How can we determine caseloads for our case management department? The question is asked by case managers from acute care hospitals and managed care organizations, and even by independents who have case managers on their staff. In this week’s Across My Desk, I am going to focus on the provider side, and issue a call to readers to provide some insight on this question. Two case managers that I have spoken to recently said they needed this information because their administration wanted to know what ‘science’ they were using to calculate staffing requirements in their case management department.

As I thought about this question, I found that it raised deeper questions that case managers need to be able to answer before they can determine appropriate caseload levels. I would like to use this week’s Across My Desk to share these questions with you and ask you to share your thoughts about them with me and other case managers. Please email me at allewellyn@dorlandhealth.com. In a future column, I will post your responses so readers can use the information. If you have supporting documentation to back up your comments, please include this research as it will assist others in formulating their policies and procedures.

What is the process for identification of patients for Case Management Services? As I have traveled around to various managed care organization, I have usually found a process in place for identification of patients who would benefit from case management. I am not so sure this is true in the provider sector. Questions that case managers need to ask are: How patients identified for case management services? Once a patient is identified, to whom are they referred? Is there a clear process for patients to self-refer to case management? What are the outcomes that case managers can claim for their services to the patients they manage? Are patient satisfaction surveys done to gain patient and family perspectives on the value of case manager interventions?

How do case managers show their return on investment for their services? I spoke to two hospital case managers recently, and learned that their salaries are less than their fellow RN staff nurses in their respective facilities. Yet, they work longer hours and are pressured by all sides to ‘move the patient.’ I asked them why their salaries were lower than staff nurses, as I had thought that due to the expertise required, case management was an upward career move for nurses, and thus came with a higher salary. They both said that the case management department was viewed as a cost center vs. a revenue-generating center. This answer caught my attention, because if done correctly, case management SHOULD be a revenue-generating center. So I asked them the following questions: As a hospital case manager, don’t you decrease length of stay by ensuring that the patient is at the correct level of care? Don’t you work with the treating physicians to ensure that the documentation is clear to show the evidence-based rationale that allows you to provide information to payers so the plan of care is clear? If so, doesn’t this result in fewer denials and increased reimbursement for the services rendered? Don’t you take the time to educate patients and families so that they better understand their diagnoses and plans of care, as well as coordinate services for them and provide them with tools to increase their adherence? By doing this, don’t your patients better understand their diagnoses, have the tools to manage their diseases, and know who to call if they experience problems once they’re home? Do you have a way to measure decreased ED visits and lower readmission rates due to exacerbations, which result in cost savings for the organization? The answer they gave me to these questions shocked me and made me wonder about the training that acute care case managers receive regarding their roles and functions as case managers. They both said, “This is not our role! Our manager should do this, but there is no time.”

How many patients/members can a case manager handle? As highlighted by the headline to this week’s column above, this really is the million-dollar question. But it’s a difficult question to answer, because in reality, there is no universal answer; it’s one that each organization has to answer for itself because each is unique. Some of the questions whose answers can help formulate a response to this question are: What is the daily census? What is the acuity of the patients for whom your organization provides service? What model of case management are you performing? The answers to these questions can help provide you with the information you need to begin to determine the ratio of caseloads your case management staff should be handling.

In my early years of case management, I was working with my supervisor and reviewing my caseload. She recognized that the number of patients I had in my queue was high. When we looked at each patient, we also realized that the cases were complex and required my attention to ensure that patients were following the plan of care. She told me something that defined the rest of my career as a catastrophic case manager. Her words were: “If you have too many patients to manage that have high acuities, you cannot be effective. What you end up doing is putting out fires and this is NOT case management.”

The process of case management should be a proactive process, allowing the case manager to:

• Understand the individual needs of the patient through the assessment process.
• Develop a plan of care to meet those needs through collaboration with the patient and the healthcare team.
• Monitor the plan of care proactively so issues are identified early.
• Make adjustments and put interventions into place early enough to avoid costly exacerbations.

And, the case management process must include one final but critical step, and that is, in the end, to evaluate the effectiveness of the entire case management process. In this stage, the case manager should have an opportunity to perform a post review of the plan of care and to document the outcomes achieved as a result of his or her involvement. Case managers should be able to identify several points during the evaluation stage that clearly demonstrate the value of their involvement in the case. If this value cannot be demonstrated, case managers may need to question the need for their services. Lastly, if you do not have time to follow the core components of the process case management from assessment through to post-evaluation, you probably DO have too many patients and need to determine the appropriate balance!

As I review these words, I realized that I have raised more questions than answers. I look forward to your responses so that, together, we can begin to address the million-dollar question that will allow us to determine appropriate caseloads and better understand how case managers are demonstrating the value we bring to our organizations through our involvement in the care continuum. Please email your thoughts to me at allewellyn@dorlandhealth.com.

Have a good week,

Anne Llewellyn, RN-BC, MS, BHSA, CCM, CRRN
Editor-in-Chief of Across My Desk, Case in Point magazine, and the Case Management Resource Guide
allewellyn@dorlandhealth.com