JONA
Volume 39, Number 1, pp 30-37
Copyright B 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
THE JOURNAL OF NURSING ADMINISTRATION
Case Management Delivery Models
The Impact of Indirect Care Givers on Organizational Outcomes
Patricia Thomas, PhD, RN, FACHE, NEA-BC, ACNS-BC
Objective: This study examined the effect of 2
case management delivery models on the orga-
nizational outcomes of length of stay (LOS) and
payment denials.
Background: Organizational leaders frequently
identify case management as a method to manage
LOS and demonstrate fiscal responsibility; yet,
most case management research is anecdotal,
describing specific patient populations or clinical
units for outcome measurement.
Methods: Regression analyses and analyses of
variance were used to examine the role functions
of case managers and the impact on LOS and
payment denials. Outcomes were evaluated on
medical, surgical, neurology, and cardiology pop-
ulations across general, intermediate, and intensive
levels of care.
Results: Caseload distribution and role defini-
tion had a statistically significant impact on LOS
and denial management across clincial specialty,
units, and levels of care. The role of the case
manager predicted 11% of the organizations LOS
management.
Conclusion: Case management role definition
impacts organizational success measures found in
LOS reduction and improved reimbursement. Al-
though only 11% of the LOS was predicted by the
role function of care coordinators, altering a single
RN role had a statistically significant impact on
LOS across clinical specialties and levels of care,
demonstrating that indirect care givers have an
important impact on organizational success.
Author Affiliation: Assistant Professor and Coordinator,
Clinical Nurse Leadership Program, University of Detroit
Mercy, Michigan.
Correspondence: University of Detroit Mercy, 4001 W
McNichols Road, College of Health Professions, Detroit,
Michigan 48221 (thomaspl@udmercy.edu).
30
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
In the last decade, significant changes have been
made in reimbursement policies on local, state, and
national levels. In light of the changes in healthcare
reimbursement and increasing costs, there is a need
to redefine nursing roles and care delivery systems.1-5
The case management specialty of healthcare was
created, in large part, because of the influence of
managed care, third-party payers, and reimburse-
ment systems. Care coordination, access to care,
delivery of care, resource use, and financial reim-
bursement are key aspects of the roles fulfilled by
case managers to organize care and reduce costs.2,4-6
For healthcare organizations to function suc-
cessfully, healthcare delivery models must change.
The ability to effectively and successfully lead and
manage healthcare organizations is hampered by
the historic and traditional models of care delivery
and organizational management.7-9 There are not
enough nurses to fulfill existing roles in the care
delivery system, and it is anticipated that the
shortage of nursing staff will continue in the
coming decades.7,10 The healthcare system is
becoming more complicated, creating the impera-
tive for healthcare leaders to identify strategies to
address the inefficiencies and uncoordinated
healthcare delivery systems through structure and
process. A greater understanding of professional
roles and role functions, the use of technology to
aid communication, and an understanding of
financial reimbursement methods will be necessary.
Lack of Evidence
There is a lack of empiric research on the specific
structure, role definition, and role functions in case
management that leads to organizational success.
The burden to validate and verify rationale for
using registered nurses (RNs) in job roles not
associated with direct patient care has become a
JONA  Vol. 39, No. 1  January 2009
paramount responsibility for nursing leaders.7,10
The knowledge, skills, and abilities of RNs are
viewed as organizational assets, and organizational
leaders who use RNs in case management role
functions will need to demonstrate why RN
resources should be used for administrative pur-
poses rather than in direct care roles. This study
proposes that specific RN case manager role
functions and responsibilities can be measured to
quantify case manager contributions to overall
organizational success.
Models of Case Management
Irrespective of the practice setting or model of case
management chosen, central to any case manage-
ment program are concepts of care coordination;
communication and collaboration between health-
care providers, patients, and payers; and attention
to the continuum of care for continuity of services
provided.4,5 This study was conducted to examine
the impact of 2 distinct case management delivery
models and the impact on organizational measures
of length of stay (LOS) and payment denials. The
case manager role functions were completed by
RNs in the care coordinator role.
Comparison of Traditional and Full Immersion
Delivery Models
The traditional model of case management focuses
on discharge planning and utilization reviews for
payment authorization by third-party payers. In
the traditional case management model, chart
review for utilization management functions was
expected every 3 days for contracted payers and
every 7 days for Medicare and Medicaid. Care
coordinator caseloads were between 16 and 28
patients a day.
Figure 1. Traditional and full immersion models.
JONA  Vol. 39, No. 1  January 2009
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
In addition to the focus on discharge planning
and payment authorization, the full immersion
model of case management defined additional care
coordinator role responsibilities. Documentation
expectations changed to include daily chart review;
daily electronic documentation in the utilization
management and electronic medical record; and
daily communication with attending physician
staff, consulting physicians, and bedside RN staff
for each of the patients in their caseload. Daily
interactions between professional staffs were
intended to minimize the likelihood of payment
denials from untimely communication about treat-
ment plans and interventions to third-party payers.
By improving written and verbal communication,
the care coordinator could also anticipate potential
treatment delays that could be proactively man-
aged. Caseloads for care coordinators were pre-
scribed and identified as 12 to 14 patients on
medical and neurology specialty units and 16 to 18
patients on surgical and cardiology units (Figure 1).
Research Question
To address the gap in research on organization-
wide impacts of case managers, the overall pur-
pose of the study was the comparison of LOS and
payment denial outcomes in the traditional (his-
torical) and full immersion models of case man-
agement delivery. The research question for this
study was as follows: ‘‘what is the relationship
between a specific structure, role definition, and
role functions in case management delivery that
leads to organizational success?’’ One unique
characteristic of this study was the inclusion of
cardiac, medical, surgical, and neurology patient
populations across general, intermediate, and
intensive levels of care.
31
Human Subjects Protection
Protection of human subjects was undertaken
through application and approval of this study by
the participating organizations’ institutional review
board. Data were extracted from the electronic
databases and placed into a secure password-
protected database. Only the primary investigator
and the management engineer completing data
extraction had access to the data. Data were
organized by unique patient identifiers and patient
visits to link information from disparate databases.
Assumptions
This study was completed recognizing that con-
trols over certain variables would not be possible.
Existing organizational policies were used for
the assignment of patients to a clinical unit during
the admission process. Each of the units main-
tained its clinical specialty, and no changes were
made to organizational practices related to the
hiring of staff. Physician-admitting practices were
not altered.
Data Collection
Patients in this study were adults admitted to and
discharged from medical, surgical, neurology, and
cardiology units. Data were collected by care
coordinators as part of the routine patient care
process. Baseline data were collected in the year
before the implementation of the full immersion
model using the electronic database systems. The
utilization management database was used to
record utilization management functions, payment
denials, and delays in care. Care coordinators also
documented assessment and evaluation findings in
the electronic medical record database to commu-
nicate with healthcare team members.
Design
Causal-comparative designs are used to study
relationship between variables to determine differ-
ences between groups when the groups are based
on preexisting variables or something that can-
not be manipulated.10 Causal-comparative designs
provide evidence of cause and effect that allows
for the study of relationships between independent
variables.10,11
In this study, the patients were assigned to
different care units based on clinical diagnosis,
clinical specialty, and availability of beds based on
existing organizational policies. Staff members self-
32
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
selected the clinical unit they worked on. These
practices do not allow for randomization or
control. Variables that were not controlled include
the assignment of the case manager on a clinical
unit, physician practice patterns, and assignment
of patients to available beds during the admis-
sion process.
Case Managers
Case managers in this study had a bachelor of
science in nursing as a requirement to be hired
into the care coordinator role. Years of experience
ranged from less than 1-year experience as a case
manager but no less than 3-year experience as an
RN to 7-year experience as a case manager and
more than 25 years of nursing experience.
Methods
Regression correlation analysis was used to exam-
ine the number of utilization reviews conducted by
care coordinators for each patient and the percent-
age of reviews completed to determine if the goal
of 100% daily reviews decreased LOS and pay-
ment denials. This analysis examined the correla-
tion between LOS and the number of utilization
reviews completed and comparisons between the
traditional and full immersion delivery models.
This represents a testing of the case management
delivery models to establish whether the compo-
nents of the full immersion model would be able to
statistically represent differences in LOS across
clinical specialties and levels of care.
Analysis of variance (ANOVA) was used to
examine payment denials. Denial of payment can
be complete or partial. Complete denials for care
rendered were based on the payer’s determination
that acute care was not appropriate or needed.
Partial denials were based on payer determinations
that treatment delays occurred because of ineffi-
ciencies in the organization processes, resulting in
specific numbers of days denied payment. If a
denial was not identified, the organization was
paid in full.
To examine LOS in the traditional model and
full immersion model, an ANOVA was conducted.
Length of stay was evaluated using baseline data
collected in the year before the implementation of
the full immersion delivery model on each clinical
unit and compared to the LOS post implementation.
In considering whether the differences in LOS
could be attributed to specific clinical specialties, a
1-way ANOVA was conducted to examine the LOS
and clinical unit specialty. Units included in the
study were cardiac intensive care unit, cardiac step
JONA  Vol. 39, No. 1  January 2009
 Table 1. Length of Stay (LOS) Full Immersion and Traditional Models
Standard
Patients, n Mean Deviation Median

Traditional 21,440 8.69 10.68 5.93

Full immersion 17,669 7.12 7.48 5.02
Total 39,109 7.83 9.09

SS df MS F Statistic Significance

Between groups 23,831.116 1 23,831.116 290.139 0.00

Within groups 3,212,126.700 39107 82.137

Abbreviations: MS, mean square; SS, sum of squares.

LOS in days; P G .05.

down unit, 2 general medical units, medical inten- typically examined a single unit of care or a specific
sive care unit, neurosurgery progressive care unit, diagnosis requiring care.
and a general surgical unit.
Utilization Reviews Completed
Utilization review documentation was completed
Results and Findings
in the utilization management database and served
Length of Stay as the cornerstone of the differences between the
More than 39,000 patients were included in this traditional and full immersion models of case man-
study (N = 39,109). The average LOS for the agement. Documentation in the database served as
17,669 patients included in the traditional model a proxy that care coordinators reviewed the pa-
of case management was 8.69 (SD 10.68) days. tient’s medical record and had taken steps to com-
The average LOS for the 21,440 patients included municate findings with other healthcare providers.
in the full immersion model was 7.12 (SD 7.48) In addition, as a result of these reviews, steps were
days. There were statistically significant differences taken to facilitate movement of the patient through
(P = .00) between groups identified as traditional the hospital system to impact LOS. The utilization
and full immersion. The LOS was 1.57 days lower review notes are the basis for payer determinations
in the full immersion sample than in the traditional of payment for services rendered. Given an antici-
model sample. This demonstrates a difference in pated 5-day LOS, a threshold of 80% of reviews
the LOS when case manager role functions, struc- completed was equal to 100%, acknowledging that
ture, and documentation expectations are defined
and measured (Table 1). The variation in LOS was
also lower in the full immersion model. The
traditional model median LOS was 5.93 days, Table 2. Clinical Unit and LOS
and the full immersion model median LOS was Unit n Mean SD SEM
5.02 days. This demonstrates less variation in the
process to manage LOS. Critical care 1,781 8.87a 13.40 0.32
Cardiac 6,425 6.29a 6.27 0.08
stepdown
Clinical Units Medical 8,793 7.12a 6.47 0.07
Medical 3,451 11.64a 12.19 0.21
Statistically significant differences were found on intensive caret
all of the clinical units across general, intermediate, Neurosurgical 9,839 7.65a 8.36 0.08
and intensive care units (P = .00). This demon- Surgical 8,820 8.17a 10.77 0.11
Total 39,108 7.83 9.10 0.05
strates that the full immersion model impacts are
not isolated to a particular clinical specialty, unit, Abbreviations: LOS, length of stay; SEM, standard error of the
mean; SS, sum of squares.
or level of care (Table 2). This is important be- LOS in days.
cause each unit had unique clinical specialties, Within groups: 3,163,003.25; between groups: 72,954.56.
Within and between groups statistically significant at the 95%
bedside nurse staffing patterns, years of care co- confidence interval.
ordinator experience, and physician practice pat- a
P G .05; df1 = 5; df2 = 39103; F = 180.38.
terns. Past research on case management outcomes

JONA  Vol. 39, No. 1  January 2009 33

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 Table 3. Utilization Management Reviews in Full Immersion and Traditional Models
Full
Immersion Traditional

Reviews not complete, Count 16,255 15,033 31,288

80% of days reviewed Expected count 17,141.6 14,146.4 31,288.0
Percentage within completeness 52.0 48.0 100.0
of reviewsV80% of days
that there was a review
Percentage of reviews 76.0 85.2 80.2
Adjusted residual j22.6 22.6
Count 5,121 2,608 7,729
Expected count 4,234.4 3,494.6 7,729.0
Reviews complete Count 5,121 2,608 7,729
Q80% of days reviewed Expected count 4,234.4 3,494.6 7,729.0
Percentage within completeness 66.3 33.7 100.0
of reviewsV80% of days
that there was a review
Percentage of reviews 24.0 14.8 19.8
Adjusted residual 22.6 j22.6
Total Count 21,376 17,641 39,017
Expected Count 21,376.0 17,641.0 39,017.0
Percentage within completeness 54.8 45.2 100.0
of reviewsV80% of days
that there was a review
Percentage of reviews 100.0 100.0 100.0

Significance Significance Significance

Value df (2 Sided) (2 Sided) (1 Sided)

Pearson 2 2 511.951 1 .000

Continuity correction 511.373 1 .000
Likelihood ratio 521.765 1 .000
Fisher’s exact test .000 .000
Linear-by-linear 511.938 1 .000
association
No. of valid cases 39,017

Completeness of reviews = 80% of days there was a review.

n = 39,017; P G .05.

a utilization review might not be completed on the 80% of the total utilization reviews completed
discharge day (Table 3). and documented 66% of the time. Patients cared
In the traditional model, care coordinators for using the traditional model of case management
were expected to review charts every 3 days for had 80% of the reviews complete 34% of the time
contracted payers and once every 7 days for (Table 3).
Medicare and Medicaid patients to arrange dis-
charge plans and authorize payment from third-
party payers. In the traditional model, 80% of the
utilization reviews were only completed on patients Table 4. Regression Model
15% of the time during their hospital stay. Said R R2 Adjusted R2
another way, 85% of the patients did not have a
0.334a 0.112 0.112
utilization review completed as expected in the care
coordinators role description and the organizations df F Significance
contractual requirements. Regression 2 2,449.879 .000a
In the full immersion model, care coordinators Residual 39,014
Total 39,016
were expected to complete daily chart reviews and
document in the utilization management database P G .05.
Visit length of stay in days is a dependent variable.
and electronic medical record to expedite care a
Reviews per day of stay and year/month of
through communication and coordination efforts. admissionVconstant.
Patients cared for on full immersion model units had

34 JONA  Vol. 39, No. 1  January 2009

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 Table 5. Correlation of Date of Admission and Length of Stay (LOS)
B Standard Error " T
Constant 12.559 0.128
Year/month of admission j0.009 0.005 j0.008
Reviews per day of stay j8.658 0.127 j0.332
P G .05.
B, dependent variable visit LOS in days.
The components of the full immersion model
explain 11% of the LOS value during a hospital-
ization (R2 = 0.112) (Table 4). The R2 represents the
proportion of total variation around the mean, thus
the power of the relationship between the compo-
nents of the model to a straight line (P = .00).
In examining the dependent variable of LOS
and independent variables of year and month of
admission and the number of utilization reviews
completed per day, there is statistically significance
impact of the independent variables on the depen-
dent variable (P = .00) with little collinearity. The
variance inflation factor in this regression analysis
was 1.038, well below the variance inflation factor
value of 10 that demonstrates collinearity.11 This
demonstrates that the interaction or overlap be-
tween the timing of the admission and the com-
pletion of the reviews during each stay had little
overlap in influencing LOS (Table 5).The analysis
of the pre-post model demonstrated a statistically
significant correlation between LOS and the num-
ber of reviews completed during the hospital stay
(P = .00) (Table 6).
The month and year of the admission were
used as a proxy to case manager experience given
the role changes for case managers in the full
immersion model. Examination of the year and
month of the admission did not demonstrate
statistical significance between the LOS and the
timing of the patients stay (P = .96) (Table 5). This
establishes that the experience of the care coor-
dinator completing the review and the date of
the admission in relation to the implementation of
Table 6. Correlation Length of Stay (LOS) and Number of Reviews per Day in Stay
Visit LOS
Pearson correlation Visit LOS 1.000
Year/month of admission j0.071
Reviews per day of stay j0.334
Significance (1 tailed) Visit LOS Y .000
Year/month of admission .000
Reviews per day of stay .000
n = 39017; P G .05. LOS in days.
JONA  Vol. 39, No. 1  January 2009
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Significance Variance Inflation Factor
97.973 .000
j1.666 .096 1.038
j68.379 .000 1.038
the full immersion model did not have an impact
on LOS.
On the basis of the regression correlation
(Table 5), the number of utilization reviews com-
plete was statistically significant to LOS (P = .00).
This information coupled with the timing of the
admission is important because it illustrates that
the completion of the utilization review had an
important impact on LOS management but the
timing of the admission did not influence LOS.
Denials
Using data from the utilization management data-
base, a comparison between payment denials
during the traditional and full immersion opera-
tions was undertaken. The Healthcare Financial
Management Association identifies target denial
rate benchmarks of less than 4% of gross revenue
for inpatient hospitals.12 In this study, there was a
slight increase in denials received during the year
that the full immersion model was implemented
from 1.08% to 1.28%, well within the benchmark.
Only 0.50% of the claims were not paid after
appeal. This represents increased revenue capture
of $6,553,799.00 and illustrates the effectiveness
of the denial management process based on the
information in the utilization management data-
base to demonstrate necessity of hospitalization to
third-party payers for authorization of payment.
In examination of payment status, a 1-way
ANOVA was conducted to determine if the LOS
influenced the payment status for services rendered.
The LOS did not show statistical significance in
Year/Month of Admission Reviews Per Day of Stay
j0.071 j0.334
1.000 0.191
0.191 1.000
.000
Y .000
.000 Y
35
 Table 7. Payment Status (Appealed, Denied, or Partial Denial)
n Mean
Appeal, denial or part denial 307
Completely paid 38802
Total 39109
SS
Between groups 88.284
Within groups 3,235,869.531
Total 3,235,957.815
Abbreviations: SEM, standard error of the mean; SS, sum of squares.
P G .05; dependent variable visit LOS in days.
whether the claim was paid or denied (P = .302)
(Table 7). In addition, the LOS for appealed,
denied, or partially denied cases was higher than
those paid in full. This demonstrates that LOS
was not dependent on the ability of the care coor-
dinator to obtain authorization of payment from
third-party payers to continue a hospital stay.
Discussion
The first conclusion from this study is that there
was a statistically significant reduction in LOS
when the caseload staffing patterns and role ex-
pectations for the full immersion model were im-
plemented. This outcome validates that caseload
staffing patterns and case manager role definition
do have an important contribution in organiza-
tional LOS management across clinical specialties
and levels of care. Patients cared in the full im-
mersion model demonstrated an average 1.57-day
reduction in LOS compared with those in the tra-
ditional model. Furthermore, the variance in LOS
decreased in the full immersion model, suggesting
less variation in the process of LOS management.
This is an important consideration in outcome mea-
surement and quality improvement principles that
validate that reductions in process variation dem-
onstrate greater stability in implemented processes
and less likelihood for errors.4,13
A second conclusion from the regression anal-
ysis is that role definition and caseload components
of the full immersion model explained 11% of the
LOS. Although at face value 11% seems to be a
low predictive value, in fact, it points to the ability
of the full immersion model to statistically repre-
sent differences in LOS across clinical specialties
and units. Influences such as physician practice
patterns, organizational culture, experience of the
nursing staff, and payer requirements often become
36
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SD SEM
7.30 8.17 0.47
7.84 9.10 0.05
7.83 9.10 0.05
df F Significance
1 1.067 .302
39,107
39,108
the focus of LOS management.5,8,14 In considering
the results of this study, the ability of an organi-
zation to impact LOS by changing caseloads and
role functions of one group of professionals is
significant and, more importantly, manageable
when compared with the other areas of focus that
typically influence LOS management.
A third conclusion can be made regarding the
timing of an admission, care coordinators experi-
ence, and time needed to learn a new role before
organizational impact would be realized. Organi-
zations often believe that LOS management will
improve only slightly at the start of an LOS man-
agement program, with improvements being real-
ized over time as the staff becomes more proficient
with the change.1,14 This was not demonstrated in
this study. The timing of the admission during did
not influence the LOS in a statistically significant
way. These are important findings for leaders to
consider as they plan for the implementation of full
immersion delivery model. In part, this finding
might be attributed to only changing the care
coordinators roles and functions. Physicians and
staff nurses were not asked to do anything different
in their practice other than talk to the care
coordinator daily.
Recommendations for Action
Several areas of organizational operations benefited
from this study. The finance department was
interested in the findings for 2 reasons. First, the
full immersion model was able to demonstrate
reduced LOS and increased revenue capture irre-
spective of the clinical unit for care. Second, al-
though initially the labor costs increased because of
reduced caseloads in the full immersion model, the
overall reduction in LOS brings balance to the
equation of fiscal responsibility.
JONA  Vol. 39, No. 1  January 2009
 The quality, compliance, and contracting depart-
ments used the findings relative to payment and LOS
management to communicate the organization’s abil-
ity to demonstrate statistically that payment status
does not drive discharge or LOS. This is an important
information for staff to know because patients and
families often believe that they are being discharged
sooner because of their insurance plan.
Several recommendations can be made to nursing
leaders. Given the nursing shortage, this study pro-
vides compelling evidence to closely examine the roles
and responsibilities assigned to professional nurses as
budgets and staffing plans are created. Organizational
leaders are struggling to attract, recruit, and retain
professional nurses. Given the shortage of nurses
providing care at the bedside, there is often hesitation
to take a nurse from a direct care role to complete
indirect care functions, and case managers are viewed
as indirect care givers in most organizations. This
study demonstrates that indirect care givers have an
important impact on organizational success high-
lighted in LOS reduction and reimbursement across
clinical specialties and levels of care (Figure 2).
Limitations of the Study
This study was conducted at a large Midwestern
hospital that may not reflect experiences of other
organizations in the region or country. The accep-
ted expectations for measurable outcomes driven
by contractual agreements and local practice norms
may have influenced efficiency and effectiveness. In
addition, other organizational practices may have
influenced LOS, for example, quality and process
improvement initiatives. External forces related to
reimbursement contracts, changes in patient vol-
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