CMSA Today - Issue 8, 2015 - (Page 13)
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
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
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
"By breaking down our processes into steps or tasks, we are able to
identify what works, what doesn't, and implement best practice."
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
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
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.
Need More Resources on Caseloads?
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.
Issue 8 * 2015
Table of Contents for the Digital Edition of CMSA Today - Issue 8, 2015
The Advantages of an Aging Workforce
CMSA CORPORATE PARTNERS
The Journey to Caseload Management
Featured Resource: Need More Resources on Caseloads?
Attracting and Engaging Tomorrow’s Workforce
Featured Resource: CMSA’s State of the Industry Survey 16
INDEX OF ADVERTISERS
CMSA Today - Issue 8, 2015