Guidance for a new case manager?

sclpn · Sep 3, 2012

1. Where I work we wear scrubs. Everyone doesnt keep a nice clean house.

2. Worst part is taking call especially after you have worked 8+ hours that day. Paperwork for the visit isnt too bad. Usually just one page but IDG/IDT paperwork is terrible and so are recertifications.

3. Working hospice in LTC facilities can be a challenge. Some nurses/staff follow hospice and understand it...others dont get hospice and do resent you being there.

4. Case loads depend on the census and how many case mgrs there are. We have 2 therefore case loads can be 5 to 15 pts a piece.

5. 30-60 min visits is the normal. Some families dont want to bond with you. They only want your medical advice and then want you to leave. Others get to know you and treat you as part of the family and you will find yourself in those homes much longer than 30 mins. With that said, you may not be able to stay an hour at every pts home because admissions get thrown in and daytime deaths happen.

I love being a hospice nurse. I love teaching/educating my families and pts. I love being able to care for one pt at a time. Hospice isnt for everyone and you absolutely have to do it because you love it not because you need a job.

Good luck with your job!!

MarcyRN · Sep 3, 2012

Thanks so much for your response, SCLPN! I should have clarified in my original post: I am an ICU nurse on a cardiac ICU, but I went to nursing school to work in hospice. I have finally landed my (I hope), dream position with a hospice agency. It's NOT because I need a job -- I am leaving a pretty great job for this one. Hospice is definitely my passion. Way more than cardiac nursing, for sure. I read anything and everything I can get my hands on about hospice, the dying process, etc. I just hope I'm cut out for it and have what it takes to be awesome at it. Thanks again for being the only one to respond to me! :-)

sclpn · Sep 3, 2012

Your welcome!! I actually went back to nursing school to do hospice. (Not a LPN anymore but a RN just cant figure out how to change that on here;) You sound like you already love hospice! Hospice is a passion not just a job! The best advice I can give is take care of youself!! You can get burned out super fast in hospice. Keep snacks in your car. Stopping to eat lunch isnt always doable. Take a vacation day every now and again. And if your off the clock dont answer your phone! Best of luck! you will be a great hospice nurse

loveanurse777 · Sep 3, 2012

Been in hospice for 3 months now, coming off 3 years of LTC experience.

I go back and forth with what I wear. I have my business casual clothes for days that I have care

conferences, meetings, or office days. I have scrubs for when I know I'm going to see a ton of patients and need the pockets and comfort factor.

Worst part? Definitely on-call, it just gives me anxiety not knowing who is going to call or why. I feel like I can't relax. I'm working on it though. Paper work is a lot, I get to work on it at home and e-send it which is great but then it's like you are always working on something. Try not to get behind...that's when it gets bad. I've seen nurses be 2 weeks on their charting and have their patient die before they even complete their assessment paperwork and clinical notes. That's crazy.

As for visits 30-60 sounds right. It's mostly about educating families on how to take care of their loved ones. Making sure symptoms are managed. Providing some emotional support. I have some families that treat me like I'm one of them. Others I will come in and do a quick assessment and they will push me out the door. It all depends. You will meet a lot of awesome people. It is kind of sad when you have the most awesome, sweetest patient and family...then you walk out realizing what the outcome will be. It's kind of bittersweet. Being from LTC I have to remind myself a lot that I can't cure anything. My patient was having a tough night due to ES CHF. LTC me wants a stat cxr, chem 7, CBC, rtc nebs, increase lasix etc. I had to stop myself. Remind myself that my job is to keep her comfortable. Put on her O2, HOB up, small dose of morphine and she slept comfortably the rest of the night, i sat at her bedside holding her hand for an hour at midnight. She woke up okay the next day.

Facilities. They are my least fave. Nurses do NOT want you sitting at their nurses station. They don't even like you talking to them sometimes. Of course I understand they are busy. I was them, but I was always really accommodating to hospice nurses even if the patient wasn't mine (because other nurses wouldn't even talk to them). I have been told to sit at a table in the hall and then have them lock the nurse station for lunch so I had to wait for them to go back in. I have been just blatantly ignored. But remember you have to sell your company so just smile and bear with it.

One thing I do dislike are the marketers. Every patient is VIP and they scream at you if they think you are doing things wrong or if you CAN'T make it to a noon admission because you have 5 other patients to see and one is 45 min away plus traffic...but they PROMISED that you'd be there at that time. Or they threaten you about how every facility is soooo important and "you better not lose us this account". Ugh.

Patient load b/w 8-15. About 5-6 visits a day. Plus admissions.

I do love it though.

enchantmentdis, BSN, RN · Sep 8, 2012

ALFs are the most difficult facilities to do a good job at--you'll be amazed at how exasperating the staff there are. They have limited medical staf(often an LVN who is never available); the units are locked; the med tech is off giving meds to 40-60 pts and can't give you much info, yet they are the one who called; they don't allow siderails; the pts are constantly falling; every little thing these dementia pts do is reported to the hospice and an unscheduled visit is required; they cannot give morphine half the time; they cannot give suppositories/enemas.They are babysitters and pill pushers. They don't want to lose money so they don't want the pt to die, so they really aren't hospice friendly. So when they repeatedly ask to put pt's on ICC thinking they can make us babysit the pt, they become concerned when we give the morphine and ativan to ensure a peaceful death. Losing that cash is a big deal to these facilities. It's ridiculous.

Sun0408, ASN, RN · Sep 10, 2012

Thanks so much for this question OP. I have been a ICU for a while now and it really is starting to feel like torture instead of nursing most days. So I am looking for a change. I have always had a huge passion for hospice.. I don't think it is used enough. I love trauma but we get our mix of 95 year old mets CA and still a full code with a GCS of 3, it breaks my heart to do CPR on this type of pt. I need a change..

OldPhatMC · Sep 14, 2012

Hello, all.
I am to start a new hospice case manager position in a few weeks, and am freaking out a little bit inside. Looking for your thoughts on a bunch of questions...[sNIP]
Oh, one more thing...what's your favorite thing about being a hospice case manager?

Great questions:

1. What I LIKE to wear is business casual. Draws less attention, more comfortable, doesn't scream NURSE. What I DO wear is scrubs. Both have their advantages.

2. Worst part of the job: the paperwork is bad, but I really hate lots of driving because some scheduler made promises without considering your day. I hate night admissions because the attending physicians are so hard to find. Dishonorable mention: working with Assisted Living Facilities.

3. SNF/ALF: it takes a good amount of work and the occasional pizza or cookie bribe to get on the good side of a facility staff, and even then, it may not help much. SNFs can be really cool and treat you like family, or they can be openly hostile. Get to be special friends with the wound nurse and the DON. If they love you, you can do no wrong. Any LPN/LVN charge nurse might resent you. I ALWAYS emphasize that we're all in this together and we're all nurses. We need to support each other. I offer help with studying for classes, I let the techs know that I appreciate the work they do, and I make an effort to not throw anyone under the bus. I had some of the best and worst times in Rhode Island, where hospice nurses could only provide recommendations and the facility nurse had to call the doctor about them. I've had orders modified by the LPN charge nurse because she thought I was "wrong" about my pain assessment. You're usually less likely to find the facility MD than if you call the attending MD for a home patient. And of course, in a facility, nothing is urgent. Unfortunately, shifting from facility to home patients can be a big mental leap so I'd rather have all SNF/ALF patients than a mix of facility and home patients.

4. Caseload: worst place I worked was a major university health system hospice with 18-24 patients. That was hell. Best case loads were in the 9-12 patient range. Practically speaking, 12 patients a week comes out about right if your typical patient has a frequency of two visits a week.

5. A visit should last as long as it takes to execute the plan of care. Remember you give care to the patient and the family. I always chart when supportive communications or even supportive presence are provided. Sometimes silence is a tremendous tool for helping the family feel that they are not alone. Your manager may fuss about a lot of long visits, but I try to get the vitals and review of systems done quickly so that I can just chat with the patient. It's amazing that the less rushed you seem to be, the faster they get to the real issues that they don't think to mention when you first arrive. People need time to verbalize difficult topics. After a while you'll get a sense when something is not right with a patient; its nothing magical, just spotting small changes. I like systems where they try to keep to two visits per week, because the second visit can be more focused. It also allows you to do an in-person tuck in. If you don't do a second visit, make it a priority to check in on Friday to make sure that all is well for the weekend. The on-call nurse will thank you.

My favorite thing about being a hospice case manager is seeing the tension leaving the patient and family, so that they can actually use the remaining time to bring closure and celebrate a life well lived.

MABSNRN · Sep 14, 2012

I am almost a year into my first hospice CMN job and I love it all except the on call!!! I love the patients, the families and the time I can spend with them. I love that I can wear regular clothing after 28 years of uniforms and scrubs. I love feeling that I have actually helped someone, either patient, family or both, it's a feeling that you don't often get in other jobs. I have never, ever had people be so grateful for my service either, and that is a nice feeling as well.

I'd been a nurse a long time before I got the specialty that was the "right" one for me, but the wait was so worth it. Good luck to you, I'm sure you will do well and I hope you love it as much as I do!!!

anna hoffman · Oct 21, 2012

Hello, all.
I am to start a new hospice case manager position in a few weeks, and am freaking out a little bit inside. Looking for your thoughts on a bunch of questions...appreciate any help or insights you can lend.
1. What do you wear? I know this sounds silly, but I forgot to ask if the case managers wear street clothes or scrubs? I'm thinking street clothes....but I don't know. If this is the case, I need to get shopping, as I'm currently a critical care nurse with a closet full of scrubs and then jeans.
2. What's the absolute worst part of your job? (Appreciate specifics, here...I've already been told about the horrors of the paperwork -- what kinds of charting are to be done on each patient/visit, i.e., WHY is there notoriously so much paperwork?)
3. The facility I will be working for has a lot of its clientele in skilled nursing facilities and assisted living facilities. If you work in this way, how do you get along with the facility staff? Do they resent your being there? Do they "dump" on you (i.e., leave patients unturned and in soaked briefs because they know you'll be coming soon?).
4. How big is your case load? I'm nervous about this; one person at the company said 10-12 patients; the other said 10-15.
5. As a case manager, how much time, on average, do you spend with each patient, and what do you do in that time? I've been reading on here that an average visit should run about 30-60 minutes. That seems so short to me -- what can honestly be accomplished in a half hour other than a set of vitals and an assessment, maybe a turn or dressing or undergarment change? I'm going into this specialty because I want to bond with the patients and their famillies -- not do a "drive-by" assessment in 20 minutes then have to chart about it for two hours. Am I too idealistic to believe that I'll actually have a chance to get to know my families and patients?
Tons more questions, but I'd be happy to get responses to these. Thanks again, so much, for your time?
Oh, one more thing...what's your favorite thing about being a hospice case ma

anna hoffman · Oct 21, 2012

I am also new to Hospice, case management. I have worked in nursing for about 18 years in the ED and the ICU. A little about me I moved back home to a rural area and I have an area that is a small town with rural patients and small hospital, the largest town is 70 miles away. So this is new to me also. I have been shadowing other hospice nurses, out in the field, and in the hospital for those patients I read their charts then go see them, taking their vitals do wound care and whatever else is needed to do.

Some of my patients have been on hospice to 2 years or more. I attended one meeting this week with a family on the status of the patient and her decline. This was in the hospital setting and with all the entities, (dietary, nursing, activities), I drive every two weeks 40 miles one way to meet with the director of hospice to discuss all of my patients and what is happening with them and any changes we have made in their care. He then signs the papers needed and makes any suggestions that I might not of thought of.

I also can not talk to anyone outside of the facility while eating lunch because the town is so small everybody know everyone and it is a violation of hippa law. I need to be care and discuss all patients in the office.

For uniforms I can wear what I want but when I see a patient I need to have a scrub jacket on or a lab coat. So I wear my scrubs for now, maybe later I will change to something nicer.

I have about 25 patients to see that are in patient and 6-7 outpatient, some I see daily others I see monthly just depending on the needs of the patient and what is going on.

anna hoffman · Oct 21, 2012

I am also a new hospice/case manager, in a small town. Your reply makes me feel alot better about this new endevour. I was a ICU, RN for many years and was getting burnt out fast.

Thank you