The Caseload Balance – Prioritising Patients

Caseload management is a skill that comes with experience. And this true – to a degree. Because, if it’s a skill, it can be learnt. We don’t have to wait to make the mistakes that others have made. We can learn the fundamentals in advance.

Despite this learnability, caseload management is given an underwhelming amount of air-time in most undergraduate degrees. And by underwhelming, I mean none.

Let’s examine the skill of patient management so they get the best care possible while also making sure that the physiotherapist hits a satisfaction sweet spot. That is, achieving a balance between stimulation (seeing enough patients) and burning out (treating too many patients).

What is caseload management?

Sarrah.org.au gives us a nice starting point:

Caseload management refers to the ability to manage a number of clients within a given amount of time and provide optimum services (this is the client specific aspect of workload management)

Though, we can expand on this definition. It’s true – our aim is to deliver a high level of service. But it’s just as critical to do so in a sustainable manner. That way, we provide excellent care over an extended period of time. And, as a corollary, we become more proficient and valuable too. Thus we tend to enjoy what we do and stay in the workforce.

So, let’s refine our definition:

Caseload management is the ability to manage our clients and provide them with the best level of care in the ideal timeframe. The clinician should be stimulated and not under- or overwhelmed at the end of each working day and week. This ensures her high level of patient care can be maintained over time.

The caseload forms part of a clinician’s overall workload.

This definition reveals two things:

  1. Stimulation is specific to the individual. That is, we can’t settle on an arbitrary figure for all clinicians. Doing so would crush some while leaving others bored. Rather, a caseload needs to be customised
  2. A clinician’s caseload (their direct interactions with clients) forms only part of their overall workload. There should be other components to the workday but this is rarely the case at the moment

Mastering management

Prioritise

It’s true – all patients require the same degree of due diligence. Though, paradoxically, they don’t need the same amount of physical and mental effort. Let’s look at an example:

Patient A is eighteen and has never had an injury before. She’s perfectly healthy – apart from rolling her ankle at netball training last night.

Patient B is fifty and he has a thirty-year history of lower back pain. He’s had a flare up. Oh, and his injury is affecting his work too. His employer is trying to move him on.

It’s clear that Patient B will be more challenging to manage.

So, how can we control this? That is, how can we make sure that one physiotherapist doesn’t end up with a disproportionate amount of the challenging cases?

Screening

This is something physiotherapists struggle with. Or, more accurately, we neglect it entirely. We book a patient in for their first consult without gathering enough relevant information.

Most centres work without any allocation system. And this is to the detriment of all parties involved. The patient. The physiotherapist. The medical centre.

What if we screened each patient (over the phone or via email) with a succinct questionnaire? This way, we’d collect pertinent data about who they are and what their in for.

Patient allocation

So, what are the patient variables we need to consider?

The injury and our interests

  • Where is your injury?

Knee or hip? Wrist or back?

We can send the patient to the clinician with an interest in the injured area. Doing so will develop their expertise. So, over time they deliver a higher level of care

Perhaps for new grads, different injuries could be distributed evenly. This way they develop confidence and competence for all types of complaint.

  • When did you sustain your injury?

Is it acute or chronic?

This is important, especially for new graduates. Exposure to harder, lingering cases builds an understanding of non-physical drivers of injury.

But it’s also important that newbies don’t get too many tough cases. It can be discouraging because progress is often slow (and sometimes barely visible).

Improvement in the chronic patient is never linear

Gender

A fifty-fifty split is ideal. This way we’re comfortable treating males and females (while also developing a suitable approach for each gender). However, more realistically, we need to allocate based on demographics. If the clinic sees 70% females then, our split needs to reflect this.

Also, we can adjust for clinician’s that have an interest in women’s or men’s health.

Age

This is like the gender category above – we allocate based on demographics. We can’t expect to treat 10% of patients aged 0-9, then 10% of patients aged 10-19 and so forth. It’s not realistic.

With this approach, a caseload is based on a physiotherapist’s interests and the clinic’s demographics. It won’t be perfect but it’s an improvement on what we do at present.

Also, the screening method can address weaknesses (perceived or real). For example, if a clinician isn’t particularly confident with managing shoulder injuries then, he can be allocated patients with injured shoulders. Soon, his flaw will become strong point.

Caseload management versus workload management

Next, we need to think about organising our time with more thought. Remember, our patient caseload should form only part of our total workload. Caseload and workload are not synonymous terms.

This is not well understood. As a result, a typical physiotherapists’ week looks like this:

There’s no variation. Is that sustainable?

Let’s be more strategic with our structure. What are the daily and weekly tasks that all physiotherapists should do to make them competent, confident and satisfied?

Daily tasks

  • Treating patients
  • Completing administrative work like patient notes and doctor’s letters
  • Professional development including:
    • Physiotherapy-specific – Reading current journal articles and attending courses and lectures
    • Outside of physiotherapy – Communication and management skills, for example
  • Pursuing a unique area of interest
  • Community work like educating primary school students or supporting the local sports club

Weekly tasks

  • Reviewing our patient caseload. Are our patients tracking as we would expect? What’s our plan for those who aren’t? To refer on? To review with a more experience physio?
  • Catch up on administrative work
  • Spend time bonding with the team
  • Plan for the week ahead
  • Reflect on the week. What did we do well? What could we have done better?

Now, our days and weeks have some form (rather than an amorphous blob of client interactions). This sets us up to thrive because:

  • Our week has variation (the veritable spice of life)
  • We have a system that fosters continual improvement
  • The structure should ensure important things (patient notes, professional development) and issues (satisfaction, team camaraderie) don’t slip through the cracks

Let’s move away from our archaic ways of caseload and workload management. A progressive approach will move the entire profession forward.

What are your thoughts on shifting our thinking from a caseload focus (patients, patients, patients!) to a holistic workload approach? Comment below.

Author: Andrew Cammarano

Andy writes about anything that comes to mind. Oftentimes, he repeats himself. So, if you read a post and ask yourself, "I feel like I've read this before." Chances are you have. Apart from writing, he eats a diet high in peanut butter, he exercises (and suffers from a chafed butt from performing too many sit-ups in pursuit of a six-pack) and comes up with many fantastical ideas, like his peanut butter-based chafe cream. Reach out to him to share your opinions (or if you'd like to become his chafe cream business partner).

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