The Journey to Caseload Management
Systematic Ways to Examine Work, Identify Challenges, and Support Staffing Needs
By Laura Ostrowsky, RN, CCM, MUP
The search to find the perfect case load calculator for case management seems to be never-ending.
The solution we seek is a formula: plug in the variables and, abracadabra, you know exactly how many cases a case manager can handle. The formula could be used for staffing, budgeting, scheduling, or contingency planning. As Eliza Doolittle stated, “Now wouldn’t that be loverly.”
Before you can begin to create a caseload calculator, you need to identify what it is you do and what you want to measure. Case managers have many different jobs, and case management departments have different responsibilities. Some tasks are easier to quantify. I cannot provide you with a formula, but I can provide a construct or framework for collecting information, reviewing your data, and identifying and justifying staffing needs.
The MSKCC Way
At Memorial Sloan Kettering Cancer Center (MSKCC), the case management department is responsible for utilization review and management as well as discharge planning. Reviewing cases to justify admission and continued stay is easier to measure than the discharge planning process.
To arrive at a method for identifying adequate staff needed to perform reviews, we collect the following metrics:
- Reviews requested
- Reviews completed (within deadline)
- Reviews not completed
- Number of days reviewed
To keep reviews manageable, you need to keep pace with requests. It is certainly faster to review cases every two days rather than once a week, so we have a guideline of 48-hour reviews. (Disclaimer: we are not a seven-day department and therefore have three- and four-day reviews to do on Mondays.)
We have been able to arrive at an average number of reviews/day/reviewer based on the numbers we have collected over time. We use this number plus our tracking of requested reviews, admissions, and length of stay to identify staffing needs. Because we are a DRG-exempt facility, we need to justify each day of stay, and failure to do so can result in payment denials. Denials for failure to provide clinical updates are costly, especially when the stay is justified and the denial is based on an inability to provide a review within the payer’s timeframe. While these denials may be reversible, there is the cost of appeal, submission of missing information, and delay in payment.
The Discharge Planning Process
Discharge planning is harder to quantify. You need to look at your case complexity and ask questions, such as:
- What percentage of total admissions requires clinical discharge planning?
- What kinds of discharge plans are being implemented?
Discharge plans include transfers to nursing homes, sub-acute care, rehabilitation, and inpatient hospice. Discharges to home may require equipment, oxygen, skilled nursing care, infusions, etc. A patient with one or two home care visits for a safety evaluation and reinforcement of self-care such as injections, glucose monitoring, or dressing changes is very different from someone who will be going home with infusion therapy or a wound vac. Patients reaching end of treatment options need more time to discuss changing goals of care and options available to support their goals and choices. As a service-based department, we staff based on the clinical complexity of the patients and the components of their discharge plans. Surgical services may have less complicated discharge plans than medical ones. Each hospital is different; units may provide separate and distinct services or more general.
Adopting the Lean Approach
All of the elements above helped us to identify staffing needs and justify additional staff in our budgets, but the search for a magic bullet or formula to calculate caseloads remains elusive. We are getting closer, and a number of methodologies have been applied throughout the industry with pockets of success.
A few months ago, we decided to map our workflows using the Lean approach. The goal was to standardize the way we handled everything, from performing and entering reviews to obtaining insurance authorization for discharge services. By breaking down our processes into steps or tasks, we are able to identify what works, what doesn’t, and implement best practice. Once you identify steps in your processes, you can better identify the time needed to complete steps. The process works better for some of our work than others.
For example, discharge planning remains a challenge to time and quantify. Breaking the process of discharge planning down into tasks has allowed us to identify timeframes for many of the steps in the process, including verifying insurance benefits, generating choice lists, completing homecare referrals, etc. The time needed to counsel patients and coordinate family meetings is harder to nail down.
Lean has been used to improve patient flow, streamline the admitting process, enhance bed turnover, etc. There has been limited use of it in case management, but it is a methodology that merits further exploration. It is a source for continuous process improvement. Detailed workflows provide training tools, a standard orientation process, as well as the foundation for policies and procedures. People think standardization is the same as inflexible and rigid, but this process includes constant review and implementation of new and better ways to get tasks accomplished. The purpose of standardizing workflows is to be able to identify what works and what doesn’t. Deviations from the standard need to be reviewed and a determination made as to whether they result in waste or can improve the current process.
The Journey to Caseload Management
The processes identified above are not formulaic, but they are systematic ways to examine your work, identify challenges, collect data to support your staffing needs, and begin the journey to caseload management.
Laura Ostrowsky, RN, CCM, MUP, is the director of case management at Memorial Sloan Kettering Cancer Center in New York City and the CMSA 2012 Case Manager of the Year. She holds a master’s degree in urban planning with a concentration in health planning and policy. She has been a member of CMSA since 2005 and currently serves on the board of directors of the New York City chapter. Laura has been in health care for 30 years, 25 of those in case management.
As part of the .e4 project, CMSA created the What is an Average Case Management Caseload microsite, providing articles, statistics, and downloads regarding caseloads in case management. In addition, gain access to the free Case Load Capacity Calculator, developed by Consulting Management Innovators (CMI) in partnership with CMSA and NASW.
- Provides rules and weights based on industry research and expertise;
- Can calculate comparative caseload capacities across teams of case managers specific to domain and practice setting; and
- Allows for customization to accommodate for differences in care delivery.
Try the Case Load Calculator today; inputting your data will help determine how various factors affect a case manager’s caseload and also help contribute to the overall empirical data that is needed to determine the appropriate average caseload.