"My case manager keeps changing!"

A frequently heard thing is "my case manager keeps changing" or something along those lines. High turnover is the field is a fact of life, and it affects not just case managers (i.e. recovery coaches), but also peer support staff, therapists, and occasionally the psychiatric providers. I've heard your frustration, and I've had to respond in some way that's okay by my employer.

One of the major reasons your case manager may leave (or get fired) is stress from the agency. One of the biggies for this is billing. Your case manager is under a huge amount of pressure to bill enough so that the agency does not fire her or him. One agency may call it "productivity," another agency may call it "metrics." It boils down to having to bill enough to your insurance, to justify their jobs. This is a balancing act. The agency ultimately needs to have money to stay open, and the case manager (or other staff) usually cares about you, but also has to make sure the money comes in.

How does this billing work? The worker writes a note every time she or he speaks with you, or otherwise does some kind of service for you. This note has to have a bunch of info on it, including details of what the worker did. This note is sooner or later given to insurance (most likely AHCCCS) so that payment might be made to the agency.

If the worker somehow coordinated your care, she can bill it as case management. This type of work can include leaving one of those long voicemails to you, or speaking with you on the phone and talking somehow about your care, or dealing with another agency for you. For each "unit" of case management, the agency can charge your insurance (whatever the going rate is).

Another type of service is assessment. The agency can bill insurance (usually only AHCCCS) around $230.00 for assessment. What is assessment? This could include your intake, and the long long form the worker has to fill out, which is an assessment form. It could include your annual updates. It could include a suicide risk assessment, a very good use of time when working with many of our clients--you know, the questions asked about thoughts, plans, or intent for self harm or suicide. It could include certain forms used to ask about substance use. Sometimes the need for these assessments is clear, but sometimes your case manager is under a lot of pressure from management to bill for assessments because they pay so much more. We often have discussions about how to justify the assessments so we can do them more often.

Another service is running groups. This is a good use of the time, and for each person in an hour-long group, the case manager can get 4 units billed (i.e. 15 minute units, times 4, for a total of 60 minutes). So say there are 4 people in the group, and the case manager is able to bill 16 total units.

Your case manager cannot bill for time spent driving to meet you at your home. They can get paid by the agency for how many miles they drove on the job, but this can't be billed to your insurance. If you are not home, then they cannot bill for any of it at all. Any of that time used to try to meet with you in the community is not billable, unless they actually speak with you or someone else in a way that can be billed. If you haven't signed a release of information form for the person spoken with, then we have to dance around the reason we are there, be very vague, or otherwise just say that we can't say why we are there.

The case manager has to write notes for a certain number of units a day or week. Different agencies require different number of units. The higher paying services are preferred over case management. For an assessment, some agencies count this as 8 units (big deal, do 3 or 4 of these and you've met your quota for the day), but some agencies may count it for less because they want the case manager to bill more assessments. You might think it is easy to meet the number for the day or week, but it is often a struggle. Sometimes, if something can go wrong, it will, and people won't be home, their phones are out of service, they miss their appointments, or the power goes out during a summer storm and the computers and phones won't work (or somebody drove into a utility pole nearby and the power goes out). You may need to transport someone to the crisis center, several miles away, and cannot bill insurance for the driving time, and traffic can be heavy so it takes a while. Except for the billing stress, you probably don't have a problem with taking the person to the crisis center because you got into this field to help people, not to ring a cash register.

The agencies may treat their employees is an abusive manner, or close to abusive, over the "productivity" or "metrics." The quality of the services given to you might not matter as much as the money the case manager brings in. It's almost like it is a sales job. The pressure can really get to your case manager. They may be told how replaceable they are, how bad at their jobs they are. Or they may be placed on PIP (performance improvement plan) for not billing enough. Or they may just be fired for not billing enough. On the other hand, an agency or supervisor may award a worker for billing a certain amount of money per month, for example giving out a certificate for billing $10,000 for the month.

In the end, the case manager may become tired with this, or disgusted with dealing with these requirements, or just totally stressed out, and may quit. You got into this field because you wanted to help people, but the realities of the field weigh on your conscience. Maybe you're tired of the ugly comments a supervisor makes in morning meetings. Maybe a supervisor singled you out for humiliation in a morning meeting, and you realize that the agency itself is sick. Your talents, your knowledge of how things work in the system, how to make things happen for clients, matter for very little in the face of dollar amounts. You are replaceable. You are a disposable worker, and maybe the agency can hire someone else and pay less per hour for the new worker.

As to the effect on the client, the agency might say they care, but really it doesn't matter for much. They may say things like "change is a part of life" without taking into account things like the trust you developed with your case manager (or therapist, or psychiatrist), or not having to explain your story over and over and over to different people.