Questions for case managers

I work in a 700+ bed urban hospital, case management is the discharge planner and the utilization review department. Utilization review calls all the insureers and lets them know why the pt is admitted to the hospital, what the hospital is doing and what the discharge plan is.These have to be done every 2-3 days and every time the pt goes from one unit to another. I help people who need something at discharge ie.. if you come in with pneumonia, when you leave if you need a nebulizer machine, oxygen at home and intravenous antibiotics, I arrange all that. Since everyone has different kinds of insurance, not everything is always covered, so leg work is required to find out if the thing is covered.
Some people need a medicne but have no perscription coverage, I facilitate the referral to the companies that manufacture certain drugs to be goiven ti the patient for free, example lovenox, linezolid, tarceva.
Liabilities include - patients come from less than ideal environments and you are sending them back to a potentially unsafe situation. ie If a patient comes in dirty and disheveled and has a high glucose, they are eldery, have no family support and live alone and are oriented and can make their own decisions
they decide to go home and make bad choices (doing drugs and alcohol)and you know they will not be compliant with the treatment plan or they will not show up to follow up appointments, you have to be right on time with documentation that you instructed, gave information on how to follow up or offered home nursing services that they refused because they don't want anyone to see the conditions they live in.
Ethical dillemmas abound when a patient is not competent to make decisions for themselves, although they may be oriented, they do not have "decision making capacity", have no family... When a pt thinks they can care for themselves but they are too unsteady or medically unable, do you send them off to a nursing home or back to their home where they can not take care of provideing themselves with food, or paying the bills.
When to call protective services when you find out about elder abuse happening to get the elderly persons check.. how about when the family refuses to let the loved one go in a nursing home, but they know full well they niether have the desire to care for or will not be available, because they work to care for a family member that requires way more care than they can provide.
Ethical dilemmas because insurance does not cover home nursing care for more than just a few visits and most people can not afford private duty nurse care.
It is an ethical dillema when insurance won't cover all the things a patient needs at dicharge, otr they have no insurance and can't get things like home oxygen or drug and alcohol rehab. How about the homeless, is it ever fair to turn them back on the street when it is 10 degrees out?

And lets not forget the issue of "I can't afford my medicine"......... its on the $4 list at Wal Mart for a months supply, but you can afford $4 a pack to smoke the three packs a day............

we dont want mama to go to a nursing home.... Its a SNF for sub acute rehab.... she wont be there forever....... then you find out they think the SNF will take mamas check each month that the family is using to pay their bills.

We need help paying our power bill........... you get the social worker to see them.... they then tell SW that they drive an $80,000 car.........ummmmmm.. seriously?

patients demanding pain meds........... but unhooking their PCA to go out and smoke.......... but want an Rx at discharge for 90 pills instead of 30 because of so much pain.............not to mention they get mad at you when you tell them they cant take their morphine PCA outside.

I cant take mama home today... Im waiting on my brother to come from out of state.... and besides I paid for the hotel room for another night............ mama can stay with you in the hotel room until brother gets here tomorrow.....

I'll be there tomorrow to get mama............. every day for the next week you are calling the family to come get mama.... they no longer answer phone calls from the hospital..... and show up a week later.

Mama cant come home until next week... we are going on vacation and we will lose our deposit.

The list goes on and on............. lol

Question to case managers . Where is the best school on line to take courseand get certificate??
I have found one... but tuition is very expensive.
Please help!
Thanks

edgwow and cardiotrans...you guys hit the nail on the head...LOL!
Crazy business, isn't it?! I love it, though!