RN4evr

One of the jobs done by UR, at my hospital, is looking at the medical necessity including obs vs inpt, appropriateness of services and procedures ordered, length of stay as indicated by insurance criteria, and discharge planning and dispostion. It is done concurrently based on Interquel and CMS guidelines. UR also sends all clinicals and obtains authorization from insurance companies. Lots of responsibility . This has been done by one person; a social worker who is often referred to as the case manager (not certified). This is now changing at my hospital. A case management team has been formed. It includes 3 RN's, 1 social worker and 1 coder. It is over seen by the CCO and HIM manager. The RN's coordinate the care to improve quality and continuity at the same time insuring fiscal responsibility for the patient and hospital. This includes: Assessing all admissions for medical necessity Patient advocate Clinical care coordination Coordinate the services associated with discharge (whether home or another facility) Provide patient education Provide post-care follow-up Coordinate services with other health care providers The social worker will primarily do UR: Verify coverage & benefits with the health insurers to ensure the provider is appropriately paid Our social worker also handles all psychosocial issues that involves patients and families. This is how we set up case management and UR at our facility. These are the primary responsibilites for each discipline but we work as a team and have overlapping as needed. Hope this is helpful.

I would try the ANCC (American Nurses Credentialing Center). http://www.nursecredentialing.org/NurseSpecialties/CaseManagement.aspx They have review resources and seminars, eligibility criteria in addition to sample test questions. With your 25+ years experience you may be surprised how much you know rather than what you don't know Good luck!

The facility I work in the ER nurses take whatever walks through the door and treat the immediate need then discharge them, transfer them to a larger facility, with more specialized care, or they are admitted to the floor. Our Medsurg floor takes care of patients from age 28 days to 102 yrs old! We take care of medical and surgical patients. Our ER and medsurg nurses are very busy. The main difference I see is the ER nurses triage, initially have no diagnosis, and provide immediate treatment for patients with sudden illness or trauma. Our medsurg nurses have an admitting diagnosis, treat patients before and after surgical procedures, and treat medical patients with multiple comorbidities. Hope this helps answer your question.

I have been a nurse for 25 years and feel the acuity of the patients is getting higher and higher. I currently work as a staff nurse and the assistant manager of a 22 bed medsurg unit in rural Wyoming. Our nurse to patient ratio can be anywhere from 4:1 to 7:1 depending on our census. Which in it's self is like a yoyo. Of course with the revolving door. We have a high ADT most of the time. We have even had the same nurse, admit and discharge the same patient, in the same shift. This is very labor intensive. In addition to all this the patient acuity seems to continue to go up. We staff by a matrix that is based only on numbers and not on acuity. The manager and myself try to look at the acuity of the patients but we are also held to a budgeted MH/stat by upper management. We are working on an acuity tool at the present time but it has not been approved or implemented yet. We can have a 50% admit and discharge turnover in 24hrs. Is anyone else out there seeing these types of trends? Does anybody else have a similar problem? And if so how are you dealing with it? Any input would be greatly appreciated.