[wmf]

I have been doing Case Manangement and UR at a small rural hospital - I have focused more on the utilization review more than case management because I am unsure of what to do. There has to be a better way to combine the two jobs - help me if you can.....

[martie_k]

UR keeps the numbers but case management meets the needs. If you do all you can do in meeting a patient's needs, all that they qualify for with their payor source or all that you can find "ou there" to help them if there is no payor source. Then you have done case management. Work with the doctor in getting them transferred or release in a timely manner. Call all MD's involved to coordinate discharge. Call reviews to insurance companies. Make time for family questions. That about it!!

[MollyJ]

Be patient with yourself. Case Management takes a while to find the shortest line between two points and at first it truly does take longer to do things because you're still learning. Eventually you will not be doing things the hard way so much. The problems clients have are as unique as they are.

I am a former peds CM for a state medicaid agency for tech dependent children. If I were doing CM in a hospital I would take a look at "frequent flyers" those pts. that return to your hospital and your ED ALL of the time. Also look at the pts who are costing your hospital money in insurance overruns. Cultivate your unit nurses and tell them that you want a heads up when these folks come in. Go to work trying to figure out what it is that contributes to their frequent flyer status. This means you will have to network with the doctor, the family, the community support services, local health department, the DME's, the pharms in your town to go at the problem solving. You should be networking with insurance CM's, too. Identify which dx's in your hospital result in frequent returns--these might involve certain kinds of technology, certain kinds of diagnoses. What is bringing them back in? What are they getting home and discovering they don't have?

If you identify community based needs, work with your community to develope them: this can include new mother parenting support, respite care needs (a tough nut to crack), asthma care education and many more.

Allow yourself to grow into the role and don't try to do it all at first.

Good luck.