Aggressive Case Mgr. Making me Nuts

I don't have this problem, but why can't she call/page the doctor. Actually, today we showed a case manager (during shift change while I was getting report) how to page the doctor because the doctor had put the wrong discharge in for a patient who didnt qualify for inpatient rehab! First time I've dealt with this, but thinking hospitals may be short on case managers, so hiring inexperienced not aggressive nurses to fill positions and/or insurance is fighting everything which is causing added pressure to case managers and they are trying to pass it on to us floor nurses

Oh, yeah. It's an unfortunate aspect of acute care now because of reimbursement. I've had difficulties in the past with difficult case managers wanting discharge in the morning, before I have even passes all my morning meds. This is one of the many reasons I quit bedside.

Wow. To me that's unethical. Maybe say it's against your nursing judgment and If she has a problem with it, she can talk to the doctor herself.

I am an acute care case manager(discharge planner). This is unfortunately as a result reimbursement and CMS rules. We cannot keep patients in a hospital for social reasons. I work PRN bedside and definitely understand how bedside nurses feel. Is it possible for your charge nurse (I'm hoping he/she doesn't have patients) to help with discharges. I try to call doctors for discharge orders but we have too many patients and sometimes cannot call every doctor. However, it is unethical for her to constantly say patients have to go because they are self pay. The hospital is a business and cannot provide free service to patients but we must also make sure patients are stable before we discharge them.

I don't know that it's outside your scope exactly, but I would think discharge facilitation is a case management function. If she knows the pt's insurance limitations, and she is paid to manage cases...why can't she approach the MD? (Side note--I don't know that discharging for insurance reasons =unethical... those 5-6 figure bills are very real. The mastectomy pt can be released with pain meds and home care. That's assuming she's stable, of course.) I don't imagine she's helping you with floor nursing stuff. And anyway, adding a middleman doesn't help things go more smoothly. It makes things more complicated.

We cannot discharge the mastectomy patient with home care if she is self pay unless she agrees to pay or the hospital pays for the service. We have some discounted clinics in most states that either the discharge planner or social worker can assist the patient with.

I really appreciate the advice you all gave me here and I've tried to be more laid back and not let my emotions get the best of me, when dealing with her. This CM is a LVN with lots of experience and has been at the hospital in this position for over 15 years. I've watched her and paid attention and I think a lot of what she says and how she says it, is out of habit albeit bad ones. After I wrote this we had an observer from corporate on our unit for a short period one day and she introduced herself and listened in on our morning mini patient meeting. The difference in the CM's behavior and verbiage she used was a complete transformation. One of the other nurses and I talked about it and I told her if it was like that every morning our day would be so much better and we wouldn't dread talking to her. I've also discovered when I work the weekend my day seems to go smoother since we don't have a CM on the unit. I still know who might be discharged and get orders if I need them, but there's no constant nagging by the CM steasing me out. It's a simple thing but I'll take what I can get:yes:

Have you tried to tell her something like:

I understand that patient 1 and 2 will be D/C today. When the physician finds they are ready for D/C and the D/C orders are in I will get right on it. I understand that you want to be successful as a D/C planner but talking to me several times before it actually happens is not helpful and just adds to the stress. If she runs after you before there is even a D/C order in just tell her "thanks for your concerns about my work flow but I feel you need to take a step back - I hear your concerns ".

She is probably a victim of the company's priority to make sure that patients are D/C without delay. Perhaps it makes her anxious as she will be measured against those numbers - hence the constant repetition.

OP: (a question of clarification)

Is this patient self-pay or did she get authorized from her insurance company for "2 days?" The usual stay for an uncomplicated double mastectomy is 2-3 days.

Here's my take on this. Case managers and nurses have to work together synergistically to get a patient who may be loitering discharged. After mutual consultation, the determination can be made to obtain discharge instructions. Either you or the CM can do this. Now as far as telling the patient that she is good to go, for the patient's sake and avoidance of misunderstanding or confusion, this point of contact should be ideally limited to the CM. Often enough, for one reason or another, real or imagined, the patient may have issues that can only be expertly addressed directly with the CM. So here it would be beyond your scope of practice for obvious reasons.

Now if you feel that the CM is being "very aggressive" remember that the stuff runs downhill and she may be getting flack from the CFO.

The psychological dynamics between you and the CM may be partially explained by the CM erroneously assuming that you may be "sitting" on a known quantity rather than proactively moving the patient through the continuum of care. On the other hand, your point of view may be that it takes two to tango and instead of browbeating you, pitch-in and do some of the heavy lifting. Now I'm only guessing with these comments, but unless human nature has evolved over the last several decades, I might just be onto something.

But as Rodney King used to say, "can't we all just get along?" Rather than let this discord continue, set the rules of engagement and division of labor and the things left unsaid may no longer be such an issue.

Case manager needs to call the docs, it would not fly at my facility for us to hound the floor nurses to expedite the discharge.