URAC CM 2 -- Case Manager Case Load

CM 2 provides:

The organization:
(a) Establishes guidelines for reasonable case manager caseload with supporting rationale based on factors such as severity of cases, complexity of cases, role requirements of case managers, and other relevant factors; and
(b) Applies a process to monitor caseload based on guidelines developed by the organization; and
(c) Consistent with the guidelines established in CM 2 (a), employs/contracts with an adequate number of case management personnel to provide services to the consumers of the program.

The standard is weighted “4”, and all subsections are considered to be primary elements.

On the one hand, the standard does not appear to be particularly onerous, as URAC is quite explicit in not specifying what an appropriate caseload is for a case management organization.  However, this is a bit deceptive, as the standard does have a certain degree of rigor embedded in it.

At the outset, the organization must define “caseload”, and be consistent in its application of that definition throughout its policies and procedures.  In our experience as consultants, many first-time applicants for accreditation do not meet this basic requirement at the outset of their accreditation process.

Second, the organization must develop caseload criteria which must reflect mindfulness about cases severity, complexity, and what role the case managers will play.  URAC reveals its deep respect for and association with the Case Management Society of America (“CMSA”) by referring applicants to that organization’s website (www.cmsa.org) for assistance in developing such criteria.

Third, the organization must have a mechanism for monitoring caseload with reference to these criteria.  Most organizations with which we have dealt as consultants use electronic case management tracking systems for this purpose.  Absent such software, simple spreadsheet analysis will suffice.  However, this tracking should be an ongoing activity of the case management supervisor, as the expectation of this standard is that the organization be prepared to adjust its staffing to accommodate any changes in caseload.

Fourth, the client/consumer complaint log should be sufficiently sophisticated to pick up any trends that might indicate that the caseload is getting too high.  Indicators in this category might include complaints about slow responsiveness from case managers, poor coordination, or even rude treatment by case managers.

The Program Guide suggests that an organization submit the following for purposes of the desktop review:

• Policy and procedure for determining case manager case load/staffing pattern.
• Consumer/client complaint log.
• Number of case managers/number of cases managed over the last year.

However, we recommend to our clients that they also submit any analyses or reports of caseload that they can submit.

The on-site review, the Program Guide tells us, will focus on:

• Interview with case management organization administrator(s) and supervisors.
• Interviews with randomly selected case managers.
• Review of consumer/client complaint log.
• Interview with appropriate quality management personnel.
• Caseload monitoring tool

What is interesting to note about this list of activities is the interview with appropriate quality management personnel.  This speaks to URAC’s commitment to interdepartmental coordination and integration of quality management throughout the program.  It also suggests that case manager caseload might be the subject of a Quality Improvement Project (see Core 35-37).