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Case Managemnt, Utilization Review
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edgwow specializes in Case Managemnt, Utilization Review.

Member of Sigma Theta Tau

edgwow's Latest Activity

  1. edgwow


    I an an Interqual Certified Instructor, you would need to ask your management team if you are able to call Change Health Care( formerly McKesson) in reference to your question or if there is a chain of command to follow before actually making the call to them directly. It is my understanding that facilities have a fee for calls that are made to Change Health Care. Make sure to read the little information notes , they are very helpful . Read the front page ( on the computer) for the subset you pick. There is no bending of the clinical information. You either have the information or you do not. You can not read into the clinical information provided.
  2. edgwow

    Bacterial Pneumonia

    First I thought of, What level of care are they in Med surge or ICU, are they getting IV antibiotics, if not , I think they should be to address the the crackles usually indicative of pneumonia. What does the chest x ray show, was infectious diseases consulted, sputum culture or nasal pharnyx washing sent? I am sure that with a sat of 80 the patient is getting oxygen, but with someone who has chronic lung disease, as you would with the extensive smoking and bronchitis history, they may routinely pulsox 85-89% and not be in acute respiratory distress. Those folks live with these low pulsoxes everyday, its just that no one is actually checking their pulsox every day when they are home. Were blood cultures done? Where is this patients CO2 by abg or even blood metabolic panel? 15,000WBC's are elevated but many, many people do not develop fevers until thier WBCs are over 20 or higher.They may take herbal supplements to boost their immunity, be well hydrated,and not yet exhibiting a fever. The other concern is are there actually no breath sounds on the one side possible requiring the need for a chest tube? This is probably not exactly what you were looking for but absolutely pertinent questions given the case study details described.
  3. I cracked up at the adlockwood post, how true is that - in hospital you do it all, utilization review and discharge planning , insurance medication authorization, for insurance company, you take calls all day from the hospital folks doing case mangement setting up home care auths and doing your assisgned hospital caseloads, which change daily as patients come and go out of the hospital- then you need to do daily reports and update census info
  4. edgwow

    Can any one help with salary range?

    I would expect around $55,000-60,000 no weekends or holidays, generous vacations and eventual ability to work at home
  5. Question 1) ROle, I am a discharge planner, case manager and utizilation review coordinator at a large hospital My role is to coordinate or buzz word, Transition to the next level of care for patients going home- do they require home care, have durable medical equiptment needs like a commode or a walker or oxygen, I am responsible to set those services up after I assess the need, speak with the medical team and ask social work to intervene if appropriate. I am responsible for giving the patient resources that may asassist them at home, like aging services, supPort groups, - communication between the medical team, the family and the next level of care providers is vital 2)Since in my role I have responsibilty in utilization review - older clinically experienced nurses do well here, varied backgrounds in many different specialties for the discharge planner, case manger role, my background in high tech trach and vent home care was very beneficial, another requirement, you can not be shy, you will call a lot of companies and only half know what you are talking about and then need to ask a ton of questions so you kinda get it by the end of your conversations- I had no competencies, and just learned on the job, however you must have a good set of community resources to fall back on 3) While the patient is inpatient the role is to communicate barriers to discharge to the family, patient, medical team ie: patient is 80 and lives alone and does not have available family to assist with IV antibiotic infusions, this would be a problem, so when MD says they are ready for discharge tomorrow.... Not so fast I tell them, we have kinks that need to be worked out first as they transition to another level of care home - by setting up home care the hope is to decrease readmission rates by empowering patients to take control of their health with the assistance of the home care team or referring anf identifying the patient to case mangement ( private insurers Aetna,managed medicaids)through the UR process when you call - if a patient lacks the resources at home to care for themselves, be it lack of money for getting scripts filled or no heat- if you can assist with these resources prior to discharge or give the patient the tools to follow up when home- improved outcomes 4) IN the discharge planning mode not really, I do no direct patient care, but with the utilization review piece, where you call all the insurance companies and let them know why the patient is in the hospital and what you are doing every day and how they are progressing towards discharge, we use a set of giudelines that determines the severity of the illness and the intensity of services rendered to see if they could be more cost effectively served at a different level of care ie: acute rehab or skilled nursing facility
  6. edgwow

    List of community resources in NJ?

    What area of New Jersey are you looking for and for what purpose, home care, hospice, county aging information, psych referrals, out of pocket providers once in the home- I just go to the county: example :department of health and senior services Monroe County NJ
  7. edgwow

    Discharge planning question ! Please help!

    I work for a large metropoliton hospital. The best way to anticipate needs, is to talk to the patient and the family, caregiver and ask, a hone call is very apropriate for a demented family member . What do you already have, give suggestions based on PT and OT assesssment and then ask if they have any equiptment, where is it from. Private insurers can tell you where they have made claims, not so with medicare for DME. For home care in medicare, it comes up as to which company is on board. I usually do not know of needs until the day of discharge. I always try to arrange delivery the day before or the day of, but many times it is not delivered until the next day, the only exception is home O2. It must first be delivered to the hospital, patient instructed on the use of it and then they call the DME company and let them know they are physically home. Always give the patient the # of the DME company, with what is to be delivered. Also, make sure when you get medicare patients, that you ask the DME company how much the patients financial responsibility is.Inform the patient. ie: ordered a commode for a patient, the 3 in 1 commode is 100 dollars, the patient is responsible for 20$., This avoids surprises for the patient and the family when billed from the DME.
  8. edgwow

    Case Management Jobs from Home

    Pediatric cardiology seems too specific for home CM. You could possibly get a CM position that works from home eventually in pediatrics though. To become CM certified you need to work 1 year under a certified case manager or 2 yrs doing it not under a certifie case manager, then you sit or an exam. Type in on allnurses.com case managemnt certification, there are specific guidelines on the website. This website is invaluable, scroll through some of the different posts, others have asked the same questions. Good luck.
  9. Why doesn't medicare pay for IV antibiotics? I hate the idea of sending someone with medicare as only insurance to a skilled nursing facilty (SNF) for the duration of the IV antibiotics. Doesn't Medicare see that this is a huge waste of resources by sending someone to a SNF if they don't have physical therapy needs, just a PICC or a midline and the need for IV antibiotics? This is a lose-lose situation, patient has to wait for bed availability and then risks getting an infection while at the snf. It can't be about money or they would open their eyes and see how wasteful it is. Does anyone know of a way to get medicare to cover it if there is no other secondary insurance? Does AARP coverage cover IV antibiotics if it is a secondary. Also if someone is a VA player ,and greater than 65 is it possible the VA would cover home IV antibiotics. Are there any free standing IV rooms, as part of a hospital, that are willing to put an IV in a confused patient daily for a week or two while the IV runs in as long as there is a caregiver at their side? I would appreciate any names of IV centers in the states of New Jersey, Pennsylvania or Delaware.
  10. edgwow

    Who, generally, has the most job satisfaction?

    Not inpatient!Totally overstressed always more work pile on.
  11. edgwow

    Can I do it?

    I suggest checking into Bayada nurses in home care. They have excellent training programs and you only take care of 1 patient at a time. It grows on you and you can work as much or as little as you want by doing more than 1 case and being flexible.
  12. edgwow

    teas exam frankford school of nursing

    I went to Frankford, many years ago (20 to be exact) Best of luck to you.!!!!!! Back then, you did not need to take a test.
  13. edgwow

    Oh boy...this isn't good, is it?

    As a case manager, I look for facilities to place patient's in that have frequent successful outcomes. If you explain this to your administrationis they have to see that this is what builds rereferrals. You are trying to sell substandard facilites even though you may have a rockin' staff. I give you a piece of advice. A few years ago, I worked at a summer camp., I loved the principals of it and the staff was always excellent, under an excellent director, but when parents came for open house, they were disappointed in the physical surroundings and lack of upgrades. They rather chose more expensive camps that had better physical surroundings -the lack of upgrades is really a true reflection of the financial well being of the organization. Afte iworked there for 8 years, the place just closed down and they were not able to sell it, it has beeen vacant for at least a year, due to extensive work that needed to be done, no investors wanted to rehab it.
  14. edgwow

    Trying to help..need insight

    In my large city, these pts get evaluated by the Corporation for Aging, medicaid applications are started and we wait until the actual application goes through. Many times , I have seen social workers send out over 50 referrals for facilities as far as 50 miles away, just to get them to see if they will ac cept the pt. That's a lot of faxes to send. We have had patients sit 6-7 monthes awaiting payor source and an accepting facility. Try doing this with an illegal, very ill immigrant. emergency medicaide due to hardship is possible but only good for 1 year.
  15. edgwow

    Trying to help..need insight

    Cardio Trans, I had to laugh, how many times has that happened? They think that when we say day 56 we really mean day 89, they do not understand we don't make the rules, we just have to abide by them.. LOL
  16. edgwow

    Questions for case managers

    I work in a 700+ bed urban hospital, case management is the discharge planner and the utilization review department. Utilization review calls all the insureers and lets them know why the pt is admitted to the hospital, what the hospital is doing and what the discharge plan is.These have to be done every 2-3 days and every time the pt goes from one unit to another. I help people who need something at discharge ie.. if you come in with pneumonia, when you leave if you need a nebulizer machine, oxygen at home and intravenous antibiotics, I arrange all that. Since everyone has different kinds of insurance, not everything is always covered, so leg work is required to find out if the thing is covered. Some people need a medicne but have no perscription coverage, I facilitate the referral to the companies that manufacture certain drugs to be goiven ti the patient for free, example lovenox, linezolid, tarceva. Liabilities include - patients come from less than ideal environments and you are sending them back to a potentially unsafe situation. ie If a patient comes in dirty and disheveled and has a high glucose, they are eldery, have no family support and live alone and are oriented and can make their own decisions they decide to go home and make bad choices (doing drugs and alcohol)and you know they will not be compliant with the treatment plan or they will not show up to follow up appointments, you have to be right on time with documentation that you instructed, gave information on how to follow up or offered home nursing services that they refused because they don't want anyone to see the conditions they live in. Ethical dillemmas abound when a patient is not competent to make decisions for themselves, although they may be oriented, they do not have "decision making capacity", have no family... When a pt thinks they can care for themselves but they are too unsteady or medically unable, do you send them off to a nursing home or back to their home where they can not take care of provideing themselves with food, or paying the bills. When to call protective services when you find out about elder abuse happening to get the elderly persons check.. how about when the family refuses to let the loved one go in a nursing home, but they know full well they niether have the desire to care for or will not be available, because they work to care for a family member that requires way more care than they can provide. Ethical dilemmas because insurance does not cover home nursing care for more than just a few visits and most people can not afford private duty nurse care. It is an ethical dillema when insurance won't cover all the things a patient needs at dicharge, otr they have no insurance and can't get things like home oxygen or drug and alcohol rehab. How about the homeless, is it ever fair to turn them back on the street when it is 10 degrees out?