Hospital CMs - What's the most difficult part of your job?

fmf13 · Aug 31, 2018

It depends on your typical workload and environment. At our hospital, we are supposed to handle a case load of 15-20 and do concurrent UR. I love case management, but there are many factors to a strong case management team. Here are two of my deciding factors: administration and management.

Before choosing to work in case management, look at the manager. That person will set the tone for morale and how effective the team is together. If management is not visible or good with communicating with the team, it leads to a lot of grumpy workers. This can, in turn, lower morale and retention. This is one of the biggest deciding factors of them all for me, because you can have a fantastic team but run them all off if you aren't careful.

My least favorite part of hospital case management is management by administrators who have no clue. Administration is always looking to us to discharge quickly and not lose the hospital money. This can be one of the most frustrating parts, because our first priority is the patient and not the money. It is learning how to balance that can be annoying sometimes. It is sad we can't provide everything a patient needs without also shoving them out the door.

Just a couple thoughts for you. Good luck on your journey!

d'cm · Sep 1, 2018

The most difficult? Knowing which of these duties is most important to someone over you and any given time.

2. Application of process improvement methodologies in evaluating outcomes of care

3. Coordination of communication with physicians, nursing, and staff of ancillary departments

4. Evaluation of care provided against the Length of Stay

5. Collaboration with Admitting to ensure accuracy of patient demographic and insurance information

6. Communication with patients and their families around medical plan of care and discharge plan

7. Assessment and plan for discharge needs and arrangements, including leading multi-disciplinary care conferences and morning 'flash meetings' in conjunction with Nursing.

8. Coordinates/facilitates patient care progression throughout the continuum.

a. Works collaboratively and maintains active communication with physicians, nursing, and other members of the multidisciplinary care team to effect timely and appropriate patient management.

b. Identifies and resolves delays and obstacles to discharge in a proactive manner. Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting.

c. Seeks consultation from appropriate disciplines/departments as required to expedite care and facilitate discharge.

d. Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues.

e. Collaborates with the physician and all members of the multidisciplinary team to facilitate care for designated caseload; monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis:

i) Communication of all elements critical to the plan of care to the patient/family and members of the health care team.

ii) Completion and reporting of diagnostic testing.

iii) Completion of treatment plan and discharge plan.

iv) Modification of plan of care, as necessary, to meet the ongoing needs of the patient

v) Communication to third-party payers and other relevant information to the care team

vi) Assignment of appropriate levels of care

vii) Completion of all required documentation in the IT Case Management screens, and patient records

9. Completes utilization management for assigned patients.

a. Applies approved InterQual criteria as a guideline to monitor appropriateness of admissions and continued stays and documents findings based on department standards.

b. Identifies at-risk populations using approved screening tool and follows established reporting procedures.

c. Monitors length of stay (LOS) and clinical resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas.

d. Refers cases and issues to physician advisor in compliance with department procedures and follows up as indicated.

e. Communicates with financial counselors to facilitate covered day reimbursement certification for assigned patients. Discusses payer criteria and issues on a case-by-case basis with clinical staff and follows up to resolve problems with payers as needed.

f. Monitors utilization of resources and reports to Manager. Captures and documents Avoidable Days in Case Management IT system.

g. Issues Notices of Non-coverage per hospital policy.

h. Provides Part B coverage notification for Observation patients.

i. Uphold compliance of regulatory standards for Observation patients including CMS requirement for Code 44.

10. Manages all aspects of discharge planning for assigned patients.

a. Meets directly with patient/family to assess needs and develop an individualized plan in collaboration with the physician.

b. Collaborates and communicates with multidisciplinary team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching, and ongoing evaluation.

c. Ensures/maintains plan consensus from patient/family, physician, and payer.

d. Refers appropriate cases for social work intervention based on department criteria.

e. Collaborates/communicates with external case managers.

f. Initiates and facilitates referrals to the Social Worker as defined in department policy.

g. Documents relevant discharge planning information in the System Case Management. IT system according to department standards.

h. Facilitates transfers to other facilities.

i. Follows ED Case Manager Job Description and Performance measures when assigned to ED.

11. Finance

a. Monitors bed availability on assigned unit in conjunction with nurse manager.

b. Communicates OBSERVATION LOS to patient and family. Has patient/significant other sign Acknowledgement Form as to status and tentative discharge date and time.

c. Initiates calls/communication to managed care companies, on all patients as required.

d. Assist in calling for hospital test results in absence of timely reporting to help expedite patient movement.

e. Solicits 'Patient Choice' for support services post discharge and confirms in EPIC.

f. Monitors appropriateness of resource consumption including orders for CT and MRI. Refers variances to Physician Advisor.

g. Knowledgeable about Indigent Medication Programs. Updates and posts list in Physician Lounge areas for physicians and hospitalists.

h. Works in coordination with Registration to reduce number of clerical errors in patient status. Makes sure patient insurance correct as well as status. Notifies Registration of changes needed to produce accurate Face Sheet revisions.

i. Refer appropriate patients to Financial Counselor.

j. Calls insurance company for pre-approval of high cost testing when required.

k. Applies Case Management Protocols as applicable.

12. Quality-Actively participates in clinical performance improvement activities by:

a. Assisting in the collection and reporting of indicators tracking efficiency of case management processes.

b. Use of data to drive decisions and plan/implement performance improvement strategies related for assigned patients, including fiscal, clinical, and patient satisfaction data.

c. Collection of delays in service data and data for specific performance and/or outcome indicators as determined by the director.

d. Solicits Physicians/Hospitalist in needs related to Case Management activities.

e. Attends in-service programs relative to scope of care relative to management of chronic health conditions causing readmissions such as Heart Disease, Cancer, Respiratory Conditions, Arthritis, Hypertension, Diabetes or Depression.

f. In the process of chart review screens orders and entries for appropriate signing, pended orders and dating as required by The Joint Commission/CMS. (CPOE)written.

g. Practices hospital service initiatives to improve HCAPPS scores.

h. Arrange home medications for patients to avoid unnecessary admissions.

i. Makes timely referrals to discharge entities as required. Makes referrals to Social Worker as outlined in policy.

13. Service

a. Calls and communicates with major payors to discuss pitfalls and problem cases and documents interventions in Case Management IT system.

b. Attends unit and committee meetings as required.

c. Prioritizes expedition of Observation patients on units.

d. Provides relief coverage update on patient caseload and concerns.

e. Coordinates 'end of life' discussions with physicians related to patient needs, if indicated.

f. Calls and arranges transportation arrangements for patients on discharge.

g. Assists in notification of bed availability and readiness on respective unit and communicates to appropriate personnel.

h. Notifies patient of hospital discharge time and documents date and time of patient agreement on whiteboard in patient room.

i. Confirms with attending physician consultants have signed off case.

14. Growth

a. Uses Interqual Guidelines as a coaching tool to aid physicians /hospitalists in appropriate placement of patients. Consults with Physician Advisor as appropriate.

15. Adheres to the Medical Center's Organizational Competencies and the Standards of Behavior.

ange09, ADN, RN · Oct 25, 2018

EVERYTHING! Unfortunately I was dx w/ MS and can no longer do patient care. So the place I wk has us with 22-25 pts doing utilization reviews, discharge plans, and coordination of care. I turn my phone off to get some referrals done, 10 min later I have 15 voicemails! It is the most stressful job and I truly believe it is the company & admin. I wk in So.Cal & this particular hospital pays very well, I make over 60/hr, BUT its because they work you to death! I have friends on the East Coast that love it, so everyone has a different experience... mine is horrific & Im just trying to hang in there...

ivyleaf · Nov 16, 2019

Thought I would try to revive this thread since I am interviewing for a hospital CM position next week. The recruiter didnt have any info as to specifics for the position; I am meeting w the hiring manager. I have experience in mental health, clinic, and outpatient CM. I want to learn more about UR and the acute medical side as I am interested in clinical documentation improvement. However, I'm a bit anxious about the idea of dealing with family drama. The job I have now is a manger position and I have a 0.5 FTE caseload; it is also mostly telephonic, which I have to say I enjoy more then in person..so not sure if this would be a good fit.

What is the typical caseload like for hospital CM in a day>

rymanell, BSN, RN · Nov 16, 2019

I work on a unit with 28 beds and typically have a caseload of 11 or 12 patients.

ivyleaf · Nov 16, 2019

Just now, rymanell said:
I work on a unit with 28 beds and typically have a caseload of 11 or 12 patients.

Thanks. That sounds reasonable based on what I have read. If you have time to answer, do you work at a large or small hospital, community vs academic medical center? Do you do both UR and CM? Would love to know more about your favorite vs least favorite parts of the job, esp compared to other types of nursing you have done.

Thanks in advance

rymanell, BSN, RN · Nov 16, 2019

I work for a large Catholic hospital in the Bon Secours/Mercy Health system. I do not do UR. We have a separate department for that. I was a bedside nurse on a joint replacement unit and have been a CM for about 6 months now. I love it!

I don't really have a least favorite part. I love the collaboration with the doctor with the whole team to put together a safe discharge plan for the patients. I also love the patient interaction. I feel like I can really advocate and make a difference for patients and families. It can be very stressful, especially on a Friday when doctors put in discharge orders late in the afternoon and a patient needs O2 delivered to their home, home health set up, ambulance transportation set up, and IV antibiotics at an infusion center, and a PICC line placed. This was a case yesterday and I just had to let one initial assessment wait until Monday. I don't like leaving anything undone, but I'm learning that it is sometimes impossible to do it all and it's really important to prioritize.

SDANG · Dec 26, 2019

On 9/1/2018 at 1:52 PM, d'cm said:
The most difficult? Knowing which of these duties is most important to someone over you and any given time.
2. Application of process improvement methodologies in evaluating outcomes of care
3. Coordination of communication with physicians, nursing, and staff of ancillary departments
4. Evaluation of care provided against the Length of Stay
5. Collaboration with Admitting to ensure accuracy of patient demographic and insurance information
6. Communication with patients and their families around medical plan of care and discharge plan
7. Assessment and plan for discharge needs and arrangements, including leading multi-disciplinary care conferences and morning 'flash meetings' in conjunction with Nursing.
8. Coordinates/facilitates patient care progression throughout the continuum.
a. Works collaboratively and maintains active communication with physicians, nursing, and other members of the multidisciplinary care team to effect timely and appropriate patient management.
b. Identifies and resolves delays and obstacles to discharge in a proactive manner. Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting.
c. Seeks consultation from appropriate disciplines/departments as required to expedite care and facilitate discharge.
d. Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues.
e. Collaborates with the physician and all members of the multidisciplinary team to facilitate care for designated caseload; monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis:
i) Communication of all elements critical to the plan of care to the patient/family and members of the health care team.
ii) Completion and reporting of diagnostic testing.
iii) Completion of treatment plan and discharge plan.
iv) Modification of plan of care, as necessary, to meet the ongoing needs of the patient
v) Communication to third-party payers and other relevant information to the care team
vi) Assignment of appropriate levels of care
vii) Completion of all required documentation in the IT Case Management screens, and patient records
9. Completes utilization management for assigned patients.
a. Applies approved InterQual criteria as a guideline to monitor appropriateness of admissions and continued stays and documents findings based on department standards.
b. Identifies at-risk populations using approved screening tool and follows established reporting procedures.
c. Monitors length of stay (LOS) and clinical resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas.
d. Refers cases and issues to physician advisor in compliance with department procedures and follows up as indicated.
e. Communicates with financial counselors to facilitate covered day reimbursement certification for assigned patients. Discusses payer criteria and issues on a case-by-case basis with clinical staff and follows up to resolve problems with payers as needed.
f. Monitors utilization of resources and reports to Manager. Captures and documents Avoidable Days in Case Management IT system.
g. Issues Notices of Non-coverage per hospital policy.
h. Provides Part B coverage notification for Observation patients.
i. Uphold compliance of regulatory standards for Observation patients including CMS requirement for Code 44.
10. Manages all aspects of discharge planning for assigned patients.
a. Meets directly with patient/family to assess needs and develop an individualized plan in collaboration with the physician.
b. Collaborates and communicates with multidisciplinary team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching, and ongoing evaluation.
c. Ensures/maintains plan consensus from patient/family, physician, and payer.
d. Refers appropriate cases for social work intervention based on department criteria.
e. Collaborates/communicates with external case managers.
f. Initiates and facilitates referrals to the Social Worker as defined in department policy.
g. Documents relevant discharge planning information in the System Case Management. IT system according to department standards.
h. Facilitates transfers to other facilities.
i. Follows ED Case Manager Job Description and Performance measures when assigned to ED.
11. Finance
a. Monitors bed availability on assigned unit in conjunction with nurse manager.
b. Communicates OBSERVATION LOS to patient and family. Has patient/significant other sign Acknowledgement Form as to status and tentative discharge date and time.
c. Initiates calls/communication to managed care companies, on all patients as required.
d. Assist in calling for hospital test results in absence of timely reporting to help expedite patient movement.
e. Solicits 'Patient Choice' for support services post discharge and confirms in EPIC.
f. Monitors appropriateness of resource consumption including orders for CT and MRI. Refers variances to Physician Advisor.
g. Knowledgeable about Indigent Medication Programs. Updates and posts list in Physician Lounge areas for physicians and hospitalists.
h. Works in coordination with Registration to reduce number of clerical errors in patient status. Makes sure patient insurance correct as well as status. Notifies Registration of changes needed to produce accurate Face Sheet revisions.
i. Refer appropriate patients to Financial Counselor.
j. Calls insurance company for pre-approval of high cost testing when required.
k. Applies Case Management Protocols as applicable.
12. Quality-Actively participates in clinical performance improvement activities by:
a. Assisting in the collection and reporting of indicators tracking efficiency of case management processes.
b. Use of data to drive decisions and plan/implement performance improvement strategies related for assigned patients, including fiscal, clinical, and patient satisfaction data.
c. Collection of delays in service data and data for specific performance and/or outcome indicators as determined by the director.
d. Solicits Physicians/Hospitalist in needs related to Case Management activities.
e. Attends in-service programs relative to scope of care relative to management of chronic health conditions causing readmissions such as Heart Disease, Cancer, Respiratory Conditions, Arthritis, Hypertension, Diabetes or Depression.
f. In the process of chart review screens orders and entries for appropriate signing, pended orders and dating as required by The Joint Commission/CMS. (CPOE)written.
g. Practices hospital service initiatives to improve HCAPPS scores.
h. Arrange home medications for patients to avoid unnecessary admissions.
i. Makes timely referrals to discharge entities as required. Makes referrals to Social Worker as outlined in policy.
13. Service
a. Calls and communicates with major payors to discuss pitfalls and problem cases and documents interventions in Case Management IT system.
b. Attends unit and committee meetings as required.
c. Prioritizes expedition of Observation patients on units.
d. Provides relief coverage update on patient caseload and concerns.
e. Coordinates 'end of life' discussions with physicians related to patient needs, if indicated.
f. Calls and arranges transportation arrangements for patients on discharge.
g. Assists in notification of bed availability and readiness on respective unit and communicates to appropriate personnel.
h. Notifies patient of hospital discharge time and documents date and time of patient agreement on whiteboard in patient room.
i. Confirms with attending physician consultants have signed off case.
14. Growth
a. Uses Interqual Guidelines as a coaching tool to aid physicians /hospitalists in appropriate placement of patients. Consults with Physician Advisor as appropriate.
15. Adheres to the Medical Center's Organizational Competencies and the Standards of Behavior.

Whew! That is QUITE a list!!!!!

I've heard CM can be very stressful, just as stressful as being a floor nurse, but in a completely different way.

I'm hoping to transition into CM soon though..... will post if/when that happens!!