New to CM. Tips appreciated.

SummerGarden, BSN, MSN, RN · Mar 15, 2015

OP: I worked as an ED CM for years most of which was NOC shift with former ED Nursing experience as a background. I started out as an Inpatient CM before making the transfer to the ED CM position. Therefore, I was similar to those you see picking up the job rather quickly. Do not compare yourself to the others. You have the right attitude and a clinical ED background, where both help in this environment. With that said, it sounds like you are getting very good orientation, so no worries! However, I recommend that when you are on your own that you have a resource (a nurse CM or nurse CM manager) you are able to call even in the middle of the night to assist with discharge planning while you are new.

As for staying organized.... Know the priorities for your department and hit those in that order. What you will find is that you will be pulled in a million and one directions on a busy night. Do not get bogged down with the activities, no matter who tries to make that activity propriety, which is not considered a priority or within your prevue to your department (I have been asked to do things only managers are allowed to do)! The bedside nurses and MDs DO NOT know your job and do not care! So, understand that in order to do your job effectively, you need to know and be in charge of the duties and responsibilities of your positon or the ED staff will run you and ask you to do things that are outside of your scope!

There are ways to do this effectively and it is through knowledge and good communication. Knowledge you can develop over time. Good communication is a skill you need to continue to enhance as you did by bedside; in other words, be a team member and keep people informed in a positive manner. For example, if you cannot get something done yourself, there is always an alternative way or plan you can develop with the ED team to safely discharge a patient. Be creative and work fast.

In addition, it will be helpful for you to find out what organizations accept admissions in the middle of the night. This includes homeless shelters, domestic violence shelters, and residential substance abuse programs. Knowing my resources has saved me a ton of time because in the counties where I worked the answer to this question is NONE! So, I did not get too involved with placing patients that have those needs in the middle of the night. I have also trained my shift that placing patients with those needs can only occur on the day shift and by a social worker. On the other hand, I made referrals, wrote up the discharge plan, and communicated to the ED team.

In contrast, some of the SNFs took patients from my ED in the middle of the night, but not all. Thus, I knew which ones did and so I did not waste my time contacting any others. Home Health and DMEs did not provide intake or services on my shift, but I could made referrals on my shift to be followed up on the day shift. In some cases the DME company contacted me at 5 AM to confirm acceptance of my referral and delivery that day; in which case I updated my notes and the plan.

Again, do not worryâ€¦ , to be really good at this job it will take time. In fact, once you are very good, your job will look easy to outsiders and you will be surprised how many of them (the ED staff) think you do not do much of anything. Like you they will be surprised if they jump ship to become an ED CM because ED CMs work hard on all shifts, but those that are good and efficient can make the job look easy! Good luck. :)

SummerGarden, BSN, MSN, RN · Mar 16, 2015

Oopsâ€¦. I want to add something important. :) One aspect of this job you might run into is the fact that the bedside nurses and MDs will misuse you as either a social worker (we are not) or the bedside nurses will try to use you as security. The former is not as bad, but time consuming so you will need to know how to let the ED staff know that you will provide resources, but you are not a social worker and so a referral to that department (if needed) is the best thing for the patient. As for the latter, you need to nip this in the bottom ASAP if and when it starts to happen.

For example, newer nurses and ED nurses who are cowards when it comes to standing up to administrators that prefer that security not be called when a patient acts out, will call you to defuse a situation. Here is the thing, that nurse probably will not tell you that you are walking into a dangerous trap! Instead he/she will say something vague like, "The patient in room D wants to talk to you." You ask for further information in preparation to provide services to that patient and the response you receive is, "Oh, I don't know what he/she wants, but they just want to talk to you." As you walk in, the patient is throwing stuff around the room, yelling, screaming... and/or walking around in a threatening manner!! Dangerous cases are only for security and/or the police!

I have also walked into rooms, where some patients were not violent, but became angry that I came to speak to him/her because they never wanted to talk to me or someone like me (a social worker in their mind). However the ED nurse thinks he/she is giving you a really good case to care for or tackle, but the referral is actually inappropriate! The reason being, patients have the right not to have a case manager or social worker on their case. In fact, they have the right to decline our services! So, it is not OK for the bedside nurse or an MD to make a referrals to our services without asking the patient.

In short, be sure to apply boundaries! Try to educate the offending nurses. Also, inform your department's management team that you are being misused as security and/or if patients' rights are being violated by having you or social services referred to cases, where patients were not asked and/or wish to decline. If you find that such referrals continue to happen from the same staff members (that has been my experience when it comes to the ED nurses), let the ED management team know names and do not back down! Good luck! :)

Crux1024 · Mar 18, 2015

There is a report sheet that goes from CM to CM, fresh one in the AM. I had a very busy day on Friday and It was good for me to see how crazy it could get. I was assessing someone for HH and got 3 calls about consults and one for a physician to speak to me regarding OBS status rules. The focus on tasks. I think the understanding and anticipating will come with time. Thank you for the advice.

Crux1024 · Mar 18, 2015

OP:. With that said, it sounds like you are getting very good orientation, so no worries! However, I recommend that when you are on your own that you have a resource (a nurse CM or nurse CM manager) you are able to call even in the middle of the night to assist with discharge planning while you are new.
As for staying organized.... Know the priorities for your department and hit those in that order. What you will find is that you will be pulled in a million and one directions on a busy night. Do not get bogged down with the activities, no matter who tries to make that activity propriety, which is not considered a priority or within your prevue to your department (I have been asked to do things only managers are allowed to do)! The bedside nurses and MDs DO NOT know your job and do not care!
In addition, it will be helpful for you to find out what organizations accept admissions in the middle of the night. This includes homeless shelters, domestic violence shelters, and residential substance abuse programs. Knowing my resources has saved me a ton of time because in the counties where I worked the answer to this question is NONE! So, I did not get too involved with placing patients that have those needs in the middle of the night. I have also trained my shift that placing patients with those needs can only occur on the day shift and by a social worker. On the other hand, I made referrals, wrote up the discharge plan, and communicated to the ED team.

I am allowed to call my manager in the middle of the night when I cant figure things out. Everyone else on the team has also offered to be available for 3am calls. I hope I dont have to make too many. I am already trying to sift out priorities and on Friday I had literally 5 things to do at once. My preceptor stopped for one minute and she had me go over what was most important and we started to tick things off in order. You are right about the MDs and other RNs not knowing the job. I dont think I had a clear idea before I started.

There are only 2 shelters in my county and both of them accept middle of the night referrals thankfully. But learning the resources is something that I am worried about. I want to be able to offer the patients the best and most appropriate resources like DME or HH as soon as I am aware of their need. Supposedly, DME can be delivered in the middle of the night but often the people delivering are sometimes not local to the area so it can take hours.

But i appreciate the encouraging words and advice. Its obvious you and Grntea are filled with knowledge and I am grateful for the advice. It really does help.

For example, newer nurses and ED nurses who are cowards when it comes to standing up to administrators that prefer that security not be called when a patient acts out, will call you to defuse a situation. Here is the thing, that nurse probably will not tell you that you are walking into a dangerous trap! Instead he/she will say something vague like, "The patient in room D wants to talk to you." You ask for further information in preparation to provide services to that patient and the response you receive is, "Oh, I don't know what he/she wants, but they just want to talk to you." As you walk in, the patient is throwing stuff around the room, yelling, screaming... and/or walking around in a threatening manner!! Dangerous cases are only for security and/or the police!

Thats ridiculous. I dont think (or at least hope) we will have that issue. Security and staff have a good relationship and they are called as needed. I have never heard that administration didn't want us calling security. I would also hope that those RNs who I have hung in the trenches with would not put me in that kind of position. But you never know.

I have also walked into rooms, where some patients were not violent, but became angry that I came to speak to him/her because they never wanted to talk to me or someone like me (a social worker in their mind). However the ED nurse thinks he/she is giving you a really good case to care for or tackle, but the referral is actually inappropriate! The reason being, patients have the right not to have a case manager or social worker on their case. In fact, they have the right to decline our services! So, it is not OK for the bedside nurse or an MD to make a referrals to our services without asking the patient.

I have never heard of the MD or RN asking the patients if they minded a CM speaking to them but you bring up a very good point. I know that the CMs have had some issue with those who are frequent fliers or have chronic problems they don't attend to correctly. Its never gotten to shouting matches that I know of, but I know that some patients don't want to have particular conversations with us. Ill have to keep that in mind.

Also, funny you should bring up Social Workers. About one year prior to now, SW and CM merged and everyone is now a considered a case manager. So SW is to do what the RN CMs do and the RN CMs are to do what the SWs do. That being said, the ER has one social worker who hangs tightly to her role (though she is now a CM) and does a very good SW job. She leaves at 4:30 every day though. So referrals to SW are not possible as I am now technically a SW too (makes learning the job slightly more interesting/difficult). Day shift ER has an RN CM and CM/SW on every day except weekends. CMs then continue the coverage through the evening and night. What are your thoughts on that? I read another thread of yours where you very strongly advocated for SW to be in league with CMs. What happens if this is not possible? Also, have you heard of this happening before? Merged job roles?

SummerGarden, BSN, MSN, RN · Mar 19, 2015

Day shift ER has an RN CM and CM/SW on every day except weekends. CMs then continue the coverage through the evening and night. What are your thoughts on that? I read another thread of yours where you very strongly advocated for SW to be in league with CMs. What happens if this is not possible? Also, have you heard of this happening before? Merged job roles?

OP: I worked in this type of environment before and I will never do it again!

In the meantime, remain in your scope of practice, diplomatically, through deflecting/referring patients to social workers of outside organizations to fulfill those needs. Also, contact the Chaplain day, evening, and night shifts if a social worker was not available to support the patient's counseling and or emotional needs.

By the way, my advocacy did not make a difference when I worked for that organization in the capacity of ED CM, but later after losing so many nurse CMs to competitors that encouraged and had policies that kept nurses and social workers within his/her scope of practice, the organization has made great changes and added technical staff and contracted with outside social agencies to support nurse CMs in the ED. So, do not allow your managers to put you in a positon that places you working outside of your scope of practice. You can give resources, assist with shelter placements, and make referrals to outside organizations, but that is about it!

As for the social workers that are acting like nurse CMs, that is a big no no!! They are not legally allowed to provide influence to the medical model and they should not be discussing the medical side of things with MDs except to note some pertinent information to later safely discharge a patient to another setting.

With that said, I think the social worker that you mentioned who works on the day shift in your ED rocks!!! She/he knows the drill that no matter what management may want/order of the social service staff, nursing is not within his/her scope of practice. I am sure your co-workers may think he/she is lazy or not a team player, but he/she is in fact doing the right thing by remaining in his/her scope of practice. Be sure to do the same! Good luck!

NurseShel · Aug 24, 2015

Thank you OP for this post. And thank you for those commenting. I am offered an ER CM Nightshift position so I've been perusing through the CM forums (my background is ICU & NICU Nursing). Any good books for reference? I saw a suggestion in one forum but I can't seem to find that comment again. Thank you!