Bait and Switch?

CapeCodMermaid, RN · Jun 14, 2017

When I was a home health nurse, all the nurses were called Case Managers. We were responsible for deciding what services the patient needed and for how long.

Natkat, BSN, MSN, RN · Jun 14, 2017

Okay. I see. I seems like case management is a big part of the job. I wonder. Can I use that experience to look for a case management job in the future?

caliotter3 · Jun 14, 2017

They probably use the term case manager for all the RN's in the office, even if they are solely working in the field, to distinguish them from the LPN's who might be referred to as the "field staff". It sounds better. Also, the role of the RN can be more comprehensive than that of the LPN, as it is expected that the RN will be more proactive in following through on the administrative requirements of the case.

However, I would hold them to the case management promise. At some point your job should separate out from that of "field staff" and become more comprehensive, as in, you will become responsible for managing a case load, not providing routine home care to a single client on a single case.

Natkat, BSN, MSN, RN · Jun 15, 2017

Thank you. I was wondering how i was going to have that conversation. I felt like they didn't make that entirely clear in the interview, so I feel like I need to bring that up very soon. Although when I was going through the orientation information a few days ago, they said "we don't use LVNs or aids". So that sounds like I will do all the care myself.

I am starting to see some red flags. I guess the larger issue for me is that this seems to establish a pattern of deceit. Do they have a habit of not fully disclosing things we need to know? Then I overheard a staff member telling someone on the phone that they had two nurses but they are "gone" and now they have hired two more - one of them being me. I don't know if "gone" means fired or if they quit. I also heard them say that they "cleaned house" and hired all new staff. This makes me wonder if they are in the habit of just up and firing everybody one day. My supervisor and the administrator are both new to their positions. In the interview they talked about doing community health teaching and being part of community groups as a way of networking. But then one of them slipped and called it "selling". When I asked them to clarify if I would be doing sales they back-pedaled really fast, but it's out there. I am excited about giving presentations as I enjoy public speaking, but then in orientation they said that we could do this "as time allows around our patient care", so I take that to mean probably never.

I want to work as a case manager, and I was thinking if I work here for a while I could put case management on my resume. I feel like no matter how bad it is I can hang in there long enough to do that. I have a feeling this place is a hell hole. I see lots of red flags. So I wonder if I should just keep trying to get a job as a case manager some where and not waste my time trying to get experience here if it turns out that I can't sell myself as a case manager.

Katillac, RN · Jun 15, 2017

Hi, Natkat

I don't think this is exactly bait and switch; in that home health nurses manage a caseload of patients, they are in fact case managers. Hospice nurses are often referred to in the same way. But it's not case management in the way you were thinking, nor will it appear as such on a resume when you pursue case management in the future. For example, you will be collaborating with other providers, but that typically means on the phone in between visits trying to get orders, arrange labs and other therapies and resolve issues that have come up with your case load.

I can see red flags here, too. Check out the home health nurse forum, you'll be able to see that unless your case load is very small, doing the job without HHAs or LPNs means doing all the hands on care yourself plus all the assessment, education, med recs, and the documentation that already has many HH nurses at their computers until late in the evening. Not telling you about the staffing history doesn't exactly make you unable to do your job, but it sure seems their expectations do. The sales part is typical of census and profit minded HH orgs, which is all of them these days. They would ideally like to see you selling their services everywhere you go. As far as community work and networking, sounds lovely until you realize that's on top of an exhausting schedule. Bottom line, the fact that they are new at this may mean they have no idea what they are asking you to do. Honestly, I'd be more than a little concerned about my license, and unless I miss my guess this slow motion train wreck won't look especially good on your CV.

And just curious - if they have just cleaned house, who is providing services now? Who will orient you to the very extensive and convoluted documentation and requirements? What is your expected caseload? I'll bet if you posted this to the home health forum they would tell you to run like Forrest Gump.

Natkat, BSN, MSN, RN · Jun 15, 2017

Thanks for shedding some light on this. It does look like a train wreck in motion. Right now patients are being covered by nurses who work in other territories and are helping out until staff are hired and trained. I will be trained by the DON, who also does care and fills in when there is a need. She will be my clinical support person. She seems knowledgeable and capable, but I'm with you. I fear that my lack of skill will come back to bite me later. I know I would do well given enough time, but I have a feeling I'm not going to have the luxury of being fully trained before they turn me loose. I can predict that I will be in many new situations not knowing what I'm doing. I also get a feeling they will hold that against me in the end - finding errors, holding me to a standard I'm not prepared for - and maybe I'm sort of like a place holder for when they can hire a more experienced nurse. And then they'll give me the "you're just not working out" speech.

I'm not too worried about documentation. I'm the odd nurse who likes computers and technology. I started my career in medical records, and I was a medical transcriptionist for 15 years before I went to nursing school. I'm not kidding myself though. I know there will be a learning curve, but being relaxed when it comes to technology will help me get through it more quickly. And for me, the documentation and paperwork will be my favorite part! I love doing that kind of stuff.

Oh, another thing that they didn't mention in the interview was that they cover a wide territory. So it wouldn't be just driving 20 or 30 miles a day. It could be 100 or more. I would be hard pressed to see all my assigned patients in an 8-hour day.

Your clarification is helping me to see that this is not what I want to do. If I want to be a case manager, then I should keep going until I find a case management position. There are things about this I would like - for example, doing more hands-on skills that I haven't done since nursing school and wouldn't mind getting better at, autonomy to work on my own, no coworkers, no politics, no drama. But I don't think the good points will outweigh the bad stuff - long hours driving, wear and tear on my car, potential for getting in over my head without no one to help me get back out, potential safety issues and having to be in filthy houses with multiple animals and hasn't been cleaned in years. Not to mention the unstable management and the potential for having the whole thing collapse without notice.

I think I'll keep looking. Thanks for your input.

tyvin, BSN, RN · Jun 15, 2017

Welcome to nursing. Same goes with hospice; we are case managers. You have cases and you manage them.

Natkat, BSN, MSN, RN · Jun 16, 2017

Yes I get the distinction. My main question is whether being called a case manager in a hospice or home health setting could be used as case management experience when I apply for a hospital case management position.

msteeleart · Jun 16, 2017

I just left a job as an RN case manager/team leader in home health and I worked there for a little over 2 years. I learned a lot while I was there but that job is not for someone that wants to come home and relax after work. Depending on how big your territory is, once you are done with seeing patients all day, you have to come home and sit and do recertification/resumption or start of care paperwork for hours plus the nursing notes. There were days where I had 6 recerts and I was sitting up doing paperwork until I went to bed at 11 pm. I loved the flexibility of the job and it was so nice when I had nothing but visits and got my nursing notes done in between patients but unfortunately lately it was not like that. They pay you a visit and a half for recerts and resumptions and it takes more time than that. My territory started out not too bad but as time went on the RN case managers dwindled down to 2 and then I was stuck doing half the city. So I had a larger territory with a lot of driving and my pay got cut last year so it just got to be too much. Handling a caseload of about 100 patients is just too much for one nurse to handle. It didn't help that the LPNs only had nursing notes to do and they were making more than me. I just got an offer for a case manager job with a big insurance company so when I go home from work at night, I don't have a work phone that I have to monitor during my time off plus the benefits and PTO are so much better. Another thing to note, most places in home health you will not get a raise. I did not get any raise in 2 years instead my pay went down and there is no overtime pay. We used to have holiday pay if you worked but that went away too. You could always do it to get experience and then move on to something else but unless you have an extreme passion for it or need the flexibility, it is just not worth it. Another thing that I did like was some of the patients. You build a rapport and you enjoy seeing them which is what kept me there for so long, I worried about leaving them if I got another job.

CapeCodMermaid, RN · Jun 16, 2017

Yes. In this day of ACOs wanting shorter stays in the hospitals and in the SNFS, people with case management experience are in high demand. Given the (in my opinion overly optimistic) notion that most elders should be cared for at home, the combination of home care and case management experience will hold you in good stead when looking for a new job.

Natkat, BSN, MSN, RN · Jun 16, 2017

That is encouraging thank you.

The elder care situation in this country is awful. It's kind of a cliche for people to say "we don't believe in putting our family members into a home". Which is misguided and unnecessary. Back in the day when a family member became ill, they might live a year, maybe two, and there was always someone at home taking care of the house, so they could be there to provide medical care for a year or two. Nowadays people can linger for a decade or more before they die. People have no clue of the sacrifice to their personal lives and career that comes with taking care of someone in their home. And you and I have long experience seeing what happens when an over-taxed family can't provide the proper care, and then grandma comes into the hospital malnourished with a raging UTI and wound you put your fist through. Then there is the problem of abuse and exploitation that is far too common.

I wish it could become the norm that it's okay to ask for help caring for an elder family member. And I wish there was a system in place for making that happen. But that's a topic for another day.