How do you handle the difficult cases?

It sounds like you know how to do your job, but you are internalizing the drama associated with your job and it needs to stop. Learn stress management techniques you can use on a day-to-day basis. Also learn not to take everyone else's problem as your own. People have problems and you will be able to solve them all. Just continue to do your best and accept that it is good enough.

It's difficult when as case managers we are held more and more accountable for outcomes, as patients are held less and less accountable for taking care of themselves. At least that's how it seems. We even now have a fulltime staff person just to schedule follow up appointments ( and I thank God for her daily, it's really taken a huge load off of us.) Our manager is the best.. in nearly 28 years of nursing, I have never had a better director/manager than I have now. That's what makes it bearable. But her feet are held to the fire as well. Keeping costs and LOS down, while trying to come up with a safe discharge plan is vexing at times. I pretty much don't think about it after I get to the driveway, but some days the neediness really gets me down on the way home.

It's difficult when as case managers we are held more and more accountable for outcomes, as patients are held less and less accountable for taking care of themselves. At least that's how it seems. We even now have a fulltime staff person just to schedule follow up appointments ( and I thank God for her daily, it's really taken a huge load off of us.) Our manager is the best.. in nearly 28 years of nursing, I have never had a better director/manager than I have now. That's what makes it bearable. But her feet are held to the fire as well. Keeping costs and LOS down, while trying to come up with a safe discharge plan is vexing at times. I pretty much don't think about it after I get to the driveway, but some days the neediness really gets me down on the way home.

Re-quoting myself: "people have problems and you will be able to solve them all." I meant to write that , you cannot solve them all... I left out the word cannot.

In addition, I understand that you feel that case managers are being made more accountable. Actually, it is true to some degree because of the misperception of non-case managers in management who think that magically there are resources available when there are not OR that you the case manager did not do your best to discharge costly cases. No matter who has the perception... it is only a perception. The truth is that there is a limited amount of things you can do.

Thus, if the person is independent, then he/she needs to be given referrals and resources in the community that may or may not help him/her. In the case of the patient who cannot be admitted but must be conversed or cannot care for self but is an independent thinker, escalate the cases. Show you did your best and followed protocol through your documentation, but leave those cases alone emotionally.

I learned by working in another capacity that case managers really are not seen by others the way you think. For example, other staff hope you can help, but they believe you when you tell them what can be done (speaking of the positive) and how you have made arrangements to prepare for the discharge that is best for the patient.

Also, upper management will discuss complicated cases amongst themselves and make arrangements when necessary to intervene and authorize resources you do not have the authority to authorize because you have shown a necessity through your documentation and your discussions with leadership and bedside staff. By the way, your boss can stand up for herself at those meetings especially if you have the documentation that shows proper interventions and due diligence.

As for CMS standards.... CMS is what it is and do not take the massive paper work as additional need to be stressed. The person who sets up appointments, should be able to help in other clerical areas to free you up to tackle some of your paper work. Maybe your management team can look at what CMs can handoff to the clerical staff?

As for LOS, what works best are organizations that take a multi-prong approach to the matter and require multiple departments to participate and be accountable to LOS. An organization that understands that will do better in the LOS category.