Effectively Managing Your Case Load

lamazeteacher · Mar 6, 2010

A website that emails articles of note about healthcare, sent me one today, that boggled my mind. It was about a 68 year old female medical patient who was discharged from hospital with several new prescriptions for her angina, severe anemia, and inability to to perform ADLs. She lives alone.

Blood tests were ordered for her every other day, and she was given some kind of wired setup, to have her vital signs taken and submitted to her physician.

That was quite a costly endeavor, yet it never occurred to that physician to order HH care.

With the reform of health care, there will be efforts to curtail medical costs. Because of that, I predict that HH caseloads will become even greater, to prevent complications caused by noncompliance, for patients newly discharged from hospital. It will be up to nurses in HH to effectively plan and organise the care for those patients so that they will be able to stay at home safely.

The success of that program is up to those of you who are involved in their care, to thoroughly teach them how to organize their medications, report untoward effects of them, and draw their blood for tests in an accurate and timely manner. Explaining all aspects of their treatment in an effort to assure their cooperation is critical, as is reporting lack of expected progress to their physicians.

More nurses will be necessary to deliver their care, resulting in increased employment opportunities for nurses.

I wrote a response to the article, encouraging the use of HH, and hope it will yield the above results

KateRN1 · Mar 6, 2010

Can you provide a link to the article? Sounds interesting.

mendu · Mar 13, 2010

i am working in a hospital FT and i am doing PT HH. with my busy days and schedule i got in love with my personal calendar planer (monthly and day by day organizer)and computer calendar spread sheets. when i got new patient i put in SOC date, ROC, and discharge, pt ph#, their MDs, all meds, then i got 485 from my DON. then i do small care plan for myself to follow and stick to it.

then i set up chart for each of my patients so i just take it for my visits. to put in patient vitals, weigh, what education we did at given date. this way i can see trends and what we did and what i will do next time.

i do not bring any other patients informations with me just the one i see at given hour.

i dod also print out which i give to my patient and follow up next visit what he/she learnt last time. plus my agency also gives me education materials which i teach and evaluate my patient. i also ask them to sing copy of teaching materials so i can put into their chart. this is more for CMS evaluation if that would occur and to know what we did, also if someone else have to cover for me if i am not available so they know what we did.

lamazeteacher · Mar 13, 2010

i am working in a hospital ft and pt in hh. with my busy schedule i fell in love with my personal planner (monthly and day by day organizer);and computer calendar spread sheets. when i get new patients, i input their soc date, roc, and discharge, ph#, their mds, and all meds. then, when the 485 comes from the don, i do a small care plan for my part in the 485, to which i can follow and adhere.
setting up a chart for each of my patients which i keep separate from those of other patients, i take only that one into the home on my visits, to input that day's vitals, weight, and what education was given on that date. that allows me to identify trends in their progress and the results of their education; and what i plan to do at the next visit.
i give a print out to my patient, and follow up at the next visit to see what teaching he/she retained, from the last visit so i can give information the next time, that is within their ability to learn. my agency also gives me educational materials which i review with my patient to teach and evaluate their conversion of what was taught, to their practise of advised (wellness) activities. i also ask them to sign the teaching materials given to them, so i affirm their receipt of them; and put that copy into their chart, leaving another copy with them. this is more for the cms evaluation, if that occurs; and to have a record of what was done, also if someone else has to cover for me if i'm not available, they'll know what had been done already.

kalex,

your post is amazing! it shows how dedicated you and your agency are, to high standards of care. i'm sure patients appreciate that, and if they've had other agencies before yours, they would know that you're the best. i have a question about whether you get time for yourself for having fun, but that's up to you. when i began a new role in nursing, i had fun putting effort into improving the methods for myself. i imagine your agency appreciates your high work and standards.

i hope you didn't mind that i put in some grammatical and rephrasing corrections above (ok, a lot of them), into your post. that was aimed at suggesting improvments in your written work to make it more clear, and have it reach professional expectations. the arn courses are shorter, and that means that some things are dropped, such as writing skills. also in charting, we keep to a minimum of words, using a lot of alphabet "soup". (what is

cms?)

when i was an inservice coordinator, i taught nurses charting; and that it was important for it to be accurate and intelligible, as a reflection of nurses' ability to express themselves as professionals. it isn't as appropriate here, i know but i really wanted to give you some tools, such as using the same tense in a paragraph, not ending sentences with a preposition, etc. i can tell that you're bright, innovative and creative. :yeah:

mendu · Mar 14, 2010

thanks for your reply. i am foreign born but educated here RN. however i still learn english and i know it is lifetime experience for me. i work 3 x 12 night shifts per week and do home visits while my kids are at school between 7-3pm so i can still be with them at most evenings and i am able to attend their after school activities.

i am very detail oriented person and i love to see improvement at my work esp if all i do would help someone else to get better and to recover.

yes i like my agency and never had any problem with them and DOn/administrator are always there for their staff.

thanks again for all your suggestions.

cms - center for medicare and medicaid services that what most of HH agencies is reimbursed by as long as their follow their guidelines.

merrymmary · Mar 20, 2010

I love home care and I'm working 3 different agency's right now. Learning lots from each one. It's amazing how much agency's vary. You'd think they would do things the same. I will pick one agency eventually. But trying to organize myself has been a nightmare. I've ask several seasoned nurses and no one can help. It seems if your company uses laptops its a lot easier to be organized. But I'm all paper.

Anyways thank you to everyone with your great organizational skills. I will use all of them. Thank you, thank you.

lamazeteacher · Mar 20, 2010

The way I organized my assignments, was mostly geographical, as they came from agencies all over Los Angeles and Orange Counties. The traffic is much worse there, now so I wouldn't be able to work in the two counties again. I'd make the earliest ones the epicenter of my travels - the ones with fasting blood tests (first), insulin, BS, and cases having several visits daily. The further apart the visits were ordered, the later in the day I got to them, if possible. When I made my calls to those who were on Medicare, I'd always ask if the were seeing their doctor that day, as at that time, I couldn't see a patient on the same day he/she saw their doctor.

New patients' H&Ps, and those who who had visits by other nurses' progress notes were read at the beginning of the day, while I telephoned patients to assure that the time I anticipated being there was OK. I always charted in the home, telling patients what I wrote, if that was appropriate (ya know what I mean...). After half my visits were made, I'd stop at a favorite lunch place, near the labs where I had to drop off specimens ( which were kept in a cooler; and look over my written charting so far. Usually it was then that I'd round off my followup visit objectives and liaison with doctors, etc by cellphone. I wish I could have used email those days as getting through to doctors was always time wasting. In one agency the supervisor did that job. Of course getting a prompt emailed answer, would be iffy.

With that done, usually the most acutely ill patients had been seen; and I could relax some, call the "later in the day" patients to adjust the times I'd be there, or see a new admission which would necessitate shuffling patients to others or putting off visits to the next day. Since I was a "per diem" worker, not a case manager, that didn't happen often. When I was a Case Manager, many surprises were in calls from the office, so I preferred the "per diem" work.

Ah, thinking about that makes me itchy to go back to HH......

merrymmary · Mar 20, 2010

how did you keep your charts, papers, calendar, notes, reminders organized in your car. My car looks like a train wreck and the end of the day. Have to reorganize for the next day. Is that just part of the process?

lamazeteacher · Mar 20, 2010

HH nurses live in their cars, eating there when necessary, maintaining supplies and forms there, as well as charts. I found a car business organizer product at Target, that I got at least 10 years ago, was very helpful. I was able to keep charts in the file spaces, according to the order of visits, forms in a closed partition on the bottom of it, (intended for a laptop) pens, and books in a side pocket, etc. I seldom used my laptop for work, but like to keep up with email, so it stayed in its case in the trunk. Anything of monetary value is in the trunk!

My supplies for visits were in my bag, with additions made as necessary. Extra dressings, lab and the cooler contained those items, which I used only if I hadn't gotten items for specific patients, ordered. The boxes with supplies were kept in my trunk along with a change of scrubs, the cooler on the floor of the back seat ( I drive a 2 door coupe). As often as possible/necessary, I emptied a sleeve (purchased for that purpose, and hung from the passenger seat head rest) containing garbage, into those many garbage containers at shopping centers. Of course garbage from patients' homes (mostly dressings) went into their own containers for that (covered ones for dirty dressings).

I have a box for recycling paper products in the trunk of my car, which has two parts, one of which is emptied for shredding whenever I get to an office. I only shred papers that have any confidential info (like a patient's name) on them, as reuse is difficult, more expensive, and sporifice for shredded paper. If no info is on a page which got slightly dirty or a kid scrawled on it, I recycle it at home in my recycling container beside the garage.

Prevention is the name of the game, and I try to keep at the mess I've made, daily. It's impossible to have a car look like that of anyone but a HH nurse, when that's for which what it's used. When I have to take the car business organizer that faces my driver's seat off the passenger seat, I put it in an empty box kept in the trunk of my car for that purpose.

I hope that helps.

merrymmary · Mar 20, 2010

This helped a lot. It helps a lot just to know other people's car's look like this too. There's just no way around it...:) Thanks,

RyanSofie · Mar 28, 2010

Here's a tip that our Administrator gave us today when searching for that skilled need. As educated, licensed professionals, we have the knowledge to change someone's life. It's easy to go in and assess the patient, complete wound care or other tangible skills, but we must remember that it really is our duty to effect change in the patient's life. Our ability to teach them life-altering skills is our greatest nursing skill, although it is not as tangible. I can go in to a patient's home weekly and weigh him, looking for that tell-tale gain that signals a CHF exacerbation, but by teaching him to weigh himself every morning and what to look for, and when to call the doctor, I am giving that patient the tools he needs to change his lifestyle and be healthier. So when you are wondering "What is my skill here?" rather think, "How can I effect change in this person's life? What tools does he need to manage his own care?" There you will find your answers for those less-tangible skills.

In my humble opinion the greatest satisfaction in nursing is empowering our patients in a time of health care crisis and need. Illness and/or caregiving is a major change in the lives of the patient and/or family members caring for the patient at home. Assisting them in learning how to take control over the circumstances and seeing tangible proof when they return a demonstration of your teaching is so rewarding. I have went to do an SOC and the weight of the situation is palpable when a family member or patient has been inpatient and had a major change in physical health. Through the process of teaching and offering support the weight lifts , the family member or patient are then able to begin the healing process and have a better understanding of the disease processes,medications etc. At the end of a cert peroid when I do a discharge Oasis and can state "goals met" and can see in black and white the progress it is so satisfying. Of course we all have patients or caregivers who see our presence as another set of hands and do not accept the responsibility of learning. All in all at the end of a long day those who choose to empower themselves provide the reward to the clinician and make it all worthwhile.:)