CM/UM job questions?

[CanopyCindy]

Hi I'm Cindy. I'm a RN, diploma since 1976. I started out at a hospital school for developmentally and physically impaired children up to age 22. I then worked pretty much all over the place, except psyche and OB/Nursery. I worked in CCU & ICU, ER, OR, Recovery, Telemetry, a transtelphonic cardiac monitoring center, home care, a bit of workerman's comp and a little bit of life insurance checks. Nursing homes too....love me my elders! LOL :chuckle

Anyway, In 1991 I started working as a Utilization Reviewer for BCBS in MA. I'd get so frustrated getting out of benefit care that I applied for a CM position. I handled the non-group clients as well as the Federal and a couple of private groups (you know, the big ones!). I immediately fell in love! LOL We frequently negotiated contracts to cover our patients, in or out of their benefits. If we could show a cost saving, even if a "soft saving" we could get the ok to go out of policy for care. We routinely showed cost savings, mostly soft savings, each around 1/4 million a calendar year. But mostly, we used the numbers in our advantage to get what our people needed!

I decided to relocate to NC (from MA) and got a job setting up the CM/UM Department for an Independent Practice Association (IPA) that was just starting out. Again, we were able to get what our people needed, as long as we could show cost savings. Since the $$ was coming out of the doc's pockets, it was sometimes harder to show cost savings, but I'm pretty good at getting my way.

After the IPA I started working as a Community Case Manager at a major medical center. About 8 months later they decided to revamp the entire department and I was unable to apply for MY job because I don't have a BNS. I was recruited by an ex-coworker to start working at a company that was devloping a case management software product. They had designed the whole thing from a computer nerd and doctor's point of view and hired my friend as the CM director. Together we got the product straightened out, and set up CM protocots, assessment examples, etc and helped out initial clients set up their CM programs and start using our product. Later I got moved to QA and have been doing that for over 5yrs. I love the testing part.....and get serious input into the design, opinion as to needs of clients, etc. We now have a product with almost 800 screens and at least 5 interactive feeds. I'm very proud of the whole thing, because there's a lot of me in it. Unfortunately, because of client needs, we've mainly concentrated on the Utilization Review part of CM. We've still got our original CM screens, and some of our UM screens are useful, but we've taken the emphasis off CM and moved to UM. We are getting into some disease management, as we're now releasing a Quality Management module.

Anyway, lately things have been getting on my nerves, I'm starting to look at getting back into CM. I'd really like to do elder care, community case management. I'm currently just looking at what's out there, and I'm not terribly optomistic. I don't want to do straight UM. I at least want to have input as part of the care team, but I'd really like to get a job with negotiating care, following up, etc. Most of the ads I see....for NC, VA, and TN, seem to indicate that the utilization review is the main focus of the job....is that true? or is there more case management than the job descriptions indicate? In MA, when I left there, most "Utilization Review Nurses" reviewed the medical record and maybe talked to the patient and contacted the ins company to get authorization. The "Case Managers" were the ones talking to the docs, recomending course of action for post-hospital care, following up, etc. Now it seems "Case Manager" And "Utilization Review Nurse" are one and the same? but what's the biggest part? the CM? or the UR?

I'm also looking for some advice on how to go about taking the CCM test. What study materials, etc. I won't be able to be tested right away, because i've not done any CM for about 6yrs, but I definitly want to get certified as soon as I can. I've seen all kinds of siminars, but would prefer to not go that route....or do I have to?

Sorry, I got a little wordy here. I'm a talker, that's for sure!

Cindy

[morley]

Hey canopy,

Couldn't help but wonder if you helped develop the canopy case management software. The hospital I work at is supposed to go live with the canopy system in January and am wondering along with my coworkers if it is going to be help of hiderance to us. ANy input would be appreciated if you have had experience with the system.

CM in my hospital is a little bit of all the things you describe. We do UM,discharge planning, get auths, discuss with MD plan of care, and collaborate with SW for placement. Never a dull moment.

[CanopyCindy]

Oh yes Morley....that's my product. I work with it, in some way or another 40-50hrs a week! :)

Of course, I am partial, but I think you're going to find it a help. I'm going to assume you're using it mostly for UM and Discharge planning?

There are a lot of features, but mostly what you'll probably use are the UM/DCP screens. Your hospital ADT system should pre-populate demographics, MD, Dx, Payors, Procedures and/or DRG info. The great thing about having the ADT feed, is that we match patients and add their encounters as they happen. You can create encounters for Inpatient, Outpatient, ER, Observation, Ambulatory care, etc....any one or two types, or all. Since we match the patients, when Mrs Jones comes in for the third time, you'll know it as an alert can be sent to you. And, when you check her record, you'll find any of the resources, payors, etc you used in her previous admissions. On the Payor screens you can record your contacts. Denial screens can be set up with general dollar amounts, so you can calculate cost savings.

There are assessments for DCP, places to record what resources you use for your patient, places to record avoidable days, denials, etc. If you are also licensed with McKesson, you'll also be able to use their InterQual program to record IS/SI/DC, etc to justify the admission. Each plan can be printed. You can also (if your facility is set up for it) transmit the DCP back to your facility via HL7 feed, in either Text or HTML, for placing in the charts, sending to the doc, etc. For the feed, any changes to the encounter captured on the plan....like disch dates, DRG info....will trigger a new doc to be sent.

There is a learning curve, but I think once you get the hand of it, you'll love it! Actually, I'd LOVE to hear about your experiences. I hear all the good from Client Services, and of course the bad when something goes wrong (not too often, thankfully) but other than our initial clients, I've not talked to any other users.

Our latest and next release is the QM product. We used the CMS/JCAHO quality initiatives to build a screen where you answer questions about each initiative, which can then be reported. Our first release was the basic program, but the full release due out in the spring will gove you the capability of creating your own quality initiatives.

I am very passionate about our product.....can you tell? I test the ADT feeds (in and outbound), McKesson's product interface, and the new QM product. Other screens too, but these 3 are mine alone. I've helped design almost all the screens, workflows, etc. When I started we had less than 100 screens. Now we have almost 800....I think we'll be well over 800 with our next release. Have you visited our web-site? http://www.a4healthsystems.com/edis/canopy/

We were purchased by A4 this past January. They seem to be a very good company. They have several other products, Electronic Medical Records, a product for the ER....but I have to admit, I don't know anything about them.

OK....I'll stop for now. Please do let me know what you think....good or bad, we DO want to hear it! And who knows, maybe you'll back me up on a couple of my pet peeves! :chuckle

Cindy