Time management strategies for case managers

Time management in case management services across the continuum comprises three concepts:

1. Cognitive work rather than multitasking
2. Funneling the caseload to a workload
3. Fluid reprioritization of 8–15 “juicy jobs”

Cognitive work

Those in case management services pride themselves on their ability to multitask, for example, talking on the phone and typing on the computer at the same time. But the real challenge to time management is that case management is not a linear activity. There are many balls that a staff member is juggling at one time, such as waiting for a phone call from an adult day center while reading a physician’s progress note on another patient to prepare for a difficult phone call. Meanwhile, a staff nurse asks about a third patient who has just been given a terminal diagnosis. All of the situations are equally important, and all need mental space to address them accurately. This is not time management, but rather the enormous cognitive work required to do the job well.

Cognitive work is the thinking behind the doing. Evidence of cognitive work is being researched by Pat Potter, RN, PhD, at Barnes Jewish Hospital in St. Louis. She studied staff nurses as they went in to see their patients and tracked how many times they changed thinking categories between assessment, planning, implementing, and evaluating results of care. The RN had 82 shifts in thinking during an 8-hour shift, along with 42 interrup­tions. (Imagine how many shifts and interruptions a physician, case manager, or social worker has in a day.) The nurse was in a room 30.9 minutes per patient in addition to 15.7 minutes of cognitive work in the service of each patient. The total then was 46.6 minutes per patient. And to stay on track throughout the shift took incredible nonlinear thinking and focus. Although no similar studies have been done with case management, it could be anticipated that:

• Case managers and others are having multiple cognitive shifts hourly and have many more patients than are within a staff nurse’s assignment
• Interruptions are part of the work and increase the need for concentration
• There are implications for models that build in cognitive shifts that are just too many to handle day after day

Funneling the caseload to a workload

This text makes the distinction between caseload (the full assignment of all patients and/or families to be covered in a shift of work) and workload (the actual number of patients and/or families needing response during this shift). The caseload for a social worker covering two 25-bed units, or 50 patients and 50 families if the beds are full, is 100. The workload is going to be a smaller number based on the model. The social worker will have to determine how to “funnel” the work to a more manageable size and still follow the standards of the department as well as be able to flex for crises such as a call to help in the ED. The funnel method actually includes a case manager and social worker side by side through the day. The funnel starts with the caseload, which may be uneven and usually is, regardless of which model and assignments staff are given. (Without this kind of method and skill, case managers, social workers, and others will constantly believe that they are working harder than anyone else and that their assignments are intrinsically unfair.) The workload is dictated by the activities that are required by the model. The workload is considered to be straightforward activities that do not require extensive intervention. However, into every workload enters situations that are not straightforward and require a lot of time and work. These are the “juicy jobs” that fall to the bottom of the funnel.

Fluid reprioritization to 8–15 “juicy jobs”

Everyone in case management will agree that several patient or family situations will take up most of the day. These, along with the involved phone calls or the push back from requests of departments, physicians, or external resources, constitute those juicy jobs. It is almost impossible to delegate parts of these jobs, because they are so involved. Regardless of caseload or workload, these 8–15 mega-problems are the ones that make or break a day and, ultimately, the success of the service.

Over time, seasoned social workers and case managers learn how to spot potentially juicy jobs before they get difficult. They also establish enhanced networks to deal with some of the difficult situations. In some of the situations they learn to refer to the physician advisor if they are fortunate enough to have an effective one who works with the department. Hopefully, members of the case management service will also have a receptive and talented director whom to ask for guidance, as well as the forum of complex care rounds if there is time to refer a situation there.
 

For more information, see Case Management Models: Best Practices for Health Systems and ACOs, Second Edition.