Case Management Nursing (CM)

[traumaRUs]

Case Management encompasses several models depending on the work environment. In the hospital, the Nurse Case Manager (CM) is frequently utilized to determine the length of stay and incorporating individual patient dynamics into the equation.

Interqual (an evidence-based clinical decision support solution) is the resource most facilities use to determine the qualifications of patients with regards to their admission length. Nurse Case Managers work with physicians, other nurses, ancillary personnel as well as the patient themselves. Interqual is a proprietary program that is sold by McKesson and purchased by facilities.

Case Management encompasses risk management as it relates to the patient's length of stay. With the drawing down of hospital personnel and the tightening of purse strings across the board, CMs are seeing expansion of their roles in the hospitals. Some CMs are even doing discharge planning.

Another CM model is that of the RN responsible for a set of patients that are at high risk for readmittance to the hospital. The CM works with them to determine why they are at high risk and works to alleviate these barriers.

Reasons for Readmittance (not all-inclusive)

• Inability to afford medications
• Inability to understand discharge instructions
• Poor living conditions
• Transportation issues
• Family stressors
• Poverty in general
• Noncompliance

Working Environment

Case Management (CM) usually takes place in an office setting and work hours are usually Monday-Friday dayshift hours. CMs may wear street clothes or scrubs. In larger facilities, CM is a full-time position while in smaller facilities, you might only be employed part-time. Most CMs do not perform bedside care of the patient although they may interact with the patient.

Qualities

Experience in a variety of nursing settings

This is needed as the CM often covers several units. Few patients have only one problem when they are admitted so it is necessary for the CM to have varied experiences in order to correctly figure in co-morbidities.

Detail-oriented

The CM will be inputting information on a computer or tablet in order to determine length of stay. It is also a plus to be able to determine the nuances of a particular diagnosis. For instance, end-stage renal disease (in the US) is usually caused by hypertension or diabetes. The CM will be looking for these diagnoses and associated co-morbidities such as (for example) neuropathy, retinopathy, and cardiac disease.

Compassionate

The CM has to be able to develop a rapport with many types of people from the attending physician, to the social worker, dietician, bedside nurse, patient, and family.

Knowledgeable

• Familiar and working knowledge using InterQual or the system used at your facility in order to assess length of stay.
• Works using vast community resources
• Works with social programs including local, regional, and national rules and regulations regarding eligibility.

Education

Nursing Case Managers are Registered Nurses with at least an associate's degree in nursing (ASN/ADN). Most will hold a bachelor's degree in nursing (BSN) or a master's in nursing (MSN). Some are MSN-prepared Advanced Practice Nurses such as Nurse Practitioners or Clinical Nurse Specialists. The RN must possess a current, unencumbered RN license in the U.S. state of practice.

Certification

American Nurses Credentialing Center

• Credential: RN-BC (Nursing Case Management Certification)
• Eligibility (2020)
• Current, active, unencumbered RN license in U.S. or territory of the U.S. or hold the professional, legally recognized equivalent in another country
• 2 years full-time as an RN
• Minimum 2,000 hours clinical practice in nursing case management within the last 3 years
• Completed 30 hours of continuing education in nursing case management within the last 3 years

Commission for Case Manager Certification (CCMC)

• Credential: CCM®
• Eligibility (2020)
• Current, active, unencumbered RN license in U.S. (BSN not required)
• 12 months full-time Case Management experience - (supervised by a CCM), OR
• 24 Months Full-Time Case Management Experience (supervisor not required CCM), OR
• 12 Months Full-Time Supervisory Experience (acts as supervisor of case managers)

Salary (2020)

According to salary.com, the average Case Manager salary in the U.S. is $80,497 with a range between $73,574 and $88,174.

[B52HOLYTRINITY]

Oh man, I thought I was busy in the ICU. I have a 40 bed Ortho floor where everyone needs something and is very case management heavy. I deal with discharging to skilled rehab/skilled nursing facilities, home health (nursing/PT/OT), home infusion, hospice, and ordering DME.

Doctors will tell family members that we know if x,y,z is covered by their insurance and will be able to answer all of their questions, and we don't. We only deal with the insurance if it pertains to the aforementioned areas that I described. Family members don't like to hear that the information they are seeking can only be answered by their insurance company (1) because every insurance is different, and there are a lot of types out there, so it would be impossible for us to keep track of every one (2) We do not have the staff or the resources to be calling for all of the patients in this hospital that we are responsible for, and (3) Calling me 2 hours before your family member goes off to surgery to see if everything is going to be covered seems like something you should have figured out a while ago before an elective procedure, Karen. Long story short, doctors have a vague idea of what we do and say things that are inaccurate or make promises they can't keep to patients and their families, and they get mad at us. Also, people are idiots. Oh, and you get snide comments from the bedside crew when you can't drop everything and attend to something they think is important. If they aren't discharging today, it's not my priority. I'll get to it if I can. You have 6 beds, and I have 40.

Generally, it's pretty routine, and you know what they need, but the volume is overwhelming for someone new. And the phone calls. I get so many phone calls. A 30 min lunch break where I am not working or taking calls happens very rarely. I am all about taking 30 mins for yourself, especially when I was bedside, but in this job, it can be discharge pending. If they are here past a certain length of time, the patient's insurance can stop paying for unnecessary inpatient days as soon as the patient is medically ready to discharge, so that means that the hospital potentially loses money if the patient cannot afford to those extra expenses. Hospital throughput is also important because you don't want to have to divert patients to other hospitals because you aren't using your resources effectively and discharging people in a timely manner. You also get to hear about it and explain what's going on in an extended stay meeting that happens weekly. Many things are outside your control, like a patient getting denied from ECF because they only have Medicaid-pending, or they're a sex offender/felon, and those are hard to place. Frequently, the patient is just not medically ready, or you're waiting on family to decide whether they can afford to send their loved one to ECF on hospice or do home hospice. (By the way, Medicare will pay for hospice, but not room and board at a facility, and they also won't pay for 24 hour caregivers at home. So it becomes a private pay situation to some extent, and a lot of people aren't prepared for that. The only program I know of that will pay for room and board at ECF on hospice is Medicaid, and many people don't qualify for that.

I do like that this job isn't life and death, but to say that it is less stressful is not true. It's a different kind of stress, and it can be a lot. I have to admit that I miss working 3 days a week. Working your a s s off 5 days a week only to have 2 days off is a bummer, but I do like that I have set hours and a good routine. I've even started regularly working out and have lost almost 10lb. So there's good and bad. I know it will get better. Just rough being new, but we all know these things get better with time and experience, so I'm hangin' in there.

[ivyleaf]

40 patients sounds like WAY too many for acute care!! I have only heard of hospital case managers having between 10-25 patients!!

[B52HOLYTRINITY]

UPDATE: I moved to a med-surg unit not terribly long after my last post (so maybe on Ortho for 1.5 months). We had a gal go to home infusion, and I was able to switch floors. I like med-surg way more (more variety than Ortho), and the unit had only 15 beds (so I took extra for the split every morning, depending on who was out, but it was maybe 25 beds instead of 40). Since then, our department has implemented a new model and gone through some process changes, and SW is taking more of an active role in discharge planning within their scope, hopefully making "the towers", as we call them (like Ortho), more manageable. Then COVID happened, and my unit expanded to about 24 beds, and that is plenty for me:) I'll be moving to Dallas, TX soon and will start at UTSW. I think their model is 2 CMRNs to 1SW on a 36 bed unit, so that sounds awesome.