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We pose a series of questions to Kathy Craig, MS, RN, CCM, president of Craig Research Continuum, to learn about the growing set of tools surrounding caseload issues, including the latest on acuity methodology. Ms. Craig, who serves on NCMN (Canada) Board, PCM Editorial Board, and CMSA’s Caseload Work Group, can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Q: As someone involved on the frontlines of tackling the caseload quandary, what are the most important issues that need to be addressed and steps that need to be taken?

A: What frontline case managers ask me to solve is bringing equity to case management caseloads quickly, fairly and dependably. Supervisors and business leaders ask for a method that is objective, reportable as data, and reproducible in a way that confirms validity.

Defining and tracking caseloads must reflect the work case managers enact for their clients and must capture sufficient details while preserving a holistic picture. This is a tall order for a method or tool. Hospitals and companies develop homegrown solutions that work but have pitfalls like a lack of validation.

The solution I developed is the Acuity Tool Kit©, which was presented at the Case Management Society of America conference in 2005. Work on acuity’s evidence was published in 2007 by Professional Case Management (PCM). I configured applications for government-payer, home-visitation and national telephonic case management, and advanced the Acuity Tool into Acuity Workflow Solutions™ and an electronic acuity prototype known as eQuity™.

Q: Can you describe a good acuity method for us?

A: Acuity is the sharpness of expert vision on the case’s degree of complexity. Acuity tools permit case managers to score acuity in each case based on traditional patient-need parameters and should include work items such as intervention tasks, times and intensities necessary to stabilize and advance the client’s care delivery efficiency and appropriateness. Specifically, eQuity has a foundation of three acuity domains — client clinical need-severity, caregiver and support system need-severity, and case management intervention-intensity.

Determining case complexity should be organic, something natural to the assessments case managers do in their minds and hearts. For example, eQuity retains and mobilizes case managers’ expert assessments into discrete quantities by degrees of complexity. Mobilizing quality assessments into quantifiable data is what frontline case managers need to add dimension to their case-number portfolios and, additionally, what supervisors need to run quality-based reports. In fact, acuity reports constitute two-way dialogues between front-office decision-makers and frontline case managers about clients, cases and caseloads.

Case acuities build into a case manager’s caseload acuity as a weighted distribution of cases per acuity level. Systems stratifying caseloads should include the acuity constellation, plus parameters like skill levels and throughput imperatives. Workloads include but extend beyond caseloads by elements such as policy rules and legal formalities. Many of these were outlined in the 2008 white paper from CMSA’s Caseload Work Group in which I participated.

Q: What would practitioners and managers do with acuity data?

A: In the 2009 CMSA pre-conference acuity workshop, Bridget McKinsey, the Blue Cross Blue Shield of Massachusetts (BCBSMA) clinical management director and supervisor to the astute BluCuity project-lead Anne Flaherty-Quemere, revealed an example of using acuity data. Ms. McKinsey told how her management team convinced decision-makers that roughly 2,000 prostate cancer cases automatically triggered to go to the oncology team but with low acuity scores, should not automatically trigger full case management and that, although case managers’ caseloads would drop by 2,000 cases, no staff should be cut. The management team proposed cutting cases while keeping a full staff complement, even in a rough economy, due to the confidence they had in the BluCuity data that showed caseload acuities justified keeping all the case managers. Both requests were granted: 2,000 cases were cut and no case manager lost a job! This is the muscle you want a tool to have.

Confidence is crucial. Confidence means you have reliable, reproducible, data-derived support increasing the objective rationale by which you make judgments. For eQuity, confidence is gained by interrater reliability (IRR) tests measuring case managers’ abilities to generate same or similar acuity scores in same or similar scenarios. If you can’t demonstrate high IRR confidence, decisions based on data from the tool are subject to doubt and criticism. Decisions include new case assignments, caseload parities, and staffing decisions about client-to-case manager ratios. Staffing decisions are supervisors’ horned dilemmas. The eQuity metrics help supervisors wrestle staffing dilemmas through the Data Trifecta™ — process, performance and outcomes data.

One stream of the Data Trifecta architecture is process. Acuity process data tell you about barriers and bottlenecks to workflow efficiency and successes to emulate or export. Bottlenecks include “paperwork” or inefficiency pile-ups involved in opening new cases or transitioning cases between departments. When a process generates “artificial” work, a case manager is disinclined to send cases to a case management step-down unit even though it gets them off the caseload. Like the BCBSMA example, spotting and tackling inefficiencies can improve process backlogs and worker morale.

The Data Trifecta performance arm empowers frontline staff to dimensionalize caseloads beyond counts, and it empowers supervisors to interact with operational knowledge strengths. For example, if a case manager’s caseload is high compared to a team, the supervisor must determine whether the case manager is catching complex cases or inflating acuities (gaming the system). Subset reports can target high-acuities for case audits. As one-off outlier, you’re fortified to engage the one case manager in a robust training dialogue, exploring case manager rationale and how to score acuities correctly. If high acuities are real but crippling, you have a framework to reshape a disproportionate caseload. If the case manager is a complex-case magnet, and likes it, you’ve discovered an “R&R” opportunity — recognize and reward.

The outcomes avenue of the Data Trifecta is important to individuals with accountability for company resource and product oversight. You want managers to use data that help integrate time and dollars spent with quantity and quality service provision. The acuity outcomes metric is the difference between acuity assessed at its highest (usually initiation) and lowest (usually discharge) points. Acuity differentials can be aggregated by the case manager, team, diagnosis code and admitting physician, to name a few. Linked to other essential business reports, like in-patient, out-patient and pharmaceutical utilization, acuity outcomes data help you gain retrospective insight, refine prospective product pricing, and fortify predictive modeling enterprises.

As the old blessing goes, “May you live in interesting times.” These are interesting times in health care and in the growth of the case management profession. Indeed, I believe we live in exciting times.

Reading and Resources

Often referred to as the million-dollar question, the ideal mode of determining caseloads is edging its way to being answered. Great strides have been made through the research and development of industry leaders. In today’s climate, as health care practices and procedures fall under added scrutiny, determining caseloads is as vital a question as ever. Listed here are supplementary educational resources:

Case Management Caseload Concept Paper
Who? The Caseload Work Group, a collaboration of the Case Management Society of America and the National Association of Social Workers
What? Examining the essential components of case management caseloads
Where? Member Toolkit section, www.cmsa.org

Maximize Case Manager Effectiveness: Setting Appropriate Caseloads
Who? Three industry leaders, including expert Kathy Craig
What? Case In Point Webinar: A 90-minute online training session on the import of caseloads
When? November 4, 2009
Where? Find out more here