Home health nurse case manager's role

[MCoots]

The role of home health nurse case manager has become much more difficult in my agency and in the large HMO we are a part of. Productivity expectations, skill mix, ever increasing paperwork, sicker patients, and coordinating care in a chaotic health care environment are some of the factors that have impacted the role in recent years. It has caused us to lose excellent nurses and to have problems with recruitment. Many nurses choose to work on-call to avoid the stresses of the role. I'm wondering about what ideas other people have regarding strategies that promote successful home health nursing case management?

One idea that we have tried is giving nurses credit for the telephone calls we make to coordinate care for patients or in place of a visit. I think it's a step in the right direction

[LMSawyer]

Productivity is an industrial concept not appropriate for a human service. In the short term it appears that increasing visits per staff member and utilizing less prepared staff saves money. In the long term we have demonstrated that patients are seen more frequently, at less acuity, and that health outcomes are not as good. Cost per visit is not the appropriate measure to use. Cost per case with improved outcomes is most appropriate. Unfortunately, health care management accepts fads published as truth and adopts strategies which have no research supporting them. Research shows that professional staff providing case management under the control of the professional staff is the most cost effective, as well as leading to the most improvement in health outcomes for the people served. Fortunately, the regulators of health care, particularly Medicare (HCFA) & JCAHO, are looking at documenting patient care outcomes, and Medicare most probably mandate prospective payment soon. This will mean that managers and agencies will be forced to use evidence-based practice which supports the work of home health nurses.

[MQ Edna]

I've got an idea, but I'm not sure it will work or how/if administration would care to buy in. For the past few years I've shared a caseload with another part time Rn (I work 24 hours a week and the other nurse works 20-24). The job share and case management worked but it was killing us because of course we were always working by phone on our days off and the usual unpaid overtime.

Anyway, we both recently "left" case management and are working regular part time relief . It's definitely a RELIEF for both of us but an adjustment and I've been thinking alot about the emotional investment that case management demands. But I haven't explained the idea--sorry.

I'm hopeful that by working to relieve the same limited number of case managers (our office is fairly small), it will "relieve"

them a bit of the continuity problems anyway.

What do you think?

[jcoppola]

You are looking for strategies that promote successful home health case management. The answers are easy, the solutions are not. There is a dichotomy in the role of case manager. You are either a manager, or as an on-call nurse, (who reaps greater rewards-same pay, more time off, less stress) a producer of widgets (high number of visits). It is inherently known that when rewards are given for higher production, quality will be compromised in order to achieve this goal. When the goal is unattainable: high production and high quality, motivation is compromised. Barring a change in management's paradigm of what constitutes acceptable productivity, the solution to the problem is to manage as you are able. Evaluate your patients once a week and give re-visits to the LVN with your "lesson plan" to follow. Telephone visits are a great way of connecting with your patients. Refuse to see more patients than you can handle. Try not to do overtime more than 3 days per week and take care of yourself. Don't quit. If management questions you about your attitude or low productivity you will be given an opportunity to voice your concerns and offer to help management solve this problem. The job parameters are outdated. A new system is required.

[MCoots]

I think if we can share the case manager role and relationship with/knowledge of our patients we can be more effective. You have to make the time to have team meetings and commnuicate about the patients to do so.

I keep wanting to take the productivity issue on head on, but it is so deeply entrenched. I agree that focusing on outcomes, cost per case, and evidence based preactice will be useful.