Copper4

Hi, I am not sure of your background, but have worked in home based roles in a couple of different jobs. I would not recommend doings so without significant "hands on" experience under your belt. Most at homes jobs are relying upon nurses that have a good clinical understanding of patient issues, or symptoms, treatments plans whatever, usually only gained from clinical experiences.

I think I am late here. I worked for a managed care company doing disease management, as with everything there was both good and bad. I have always enjoyed the patient teaching aspect of nursing, so that was a positive, especially if an eager client. Down side is that job performance was completely based on the quantity of calls, and there was an expectation, unfortunately calls out, did not equal calls made, the person has to answer the phone. I worked in heart disease, so many of the calls were made to people who were working, therefore evening calls were necessary. My primary gripe was with the quotas, at that time the goal was 10-15 calls a day.

I am from the Northeast as well, but only work case management per diem. I knew RAC's were coming, but have not heard anything more in terms of the effect on payment. How has it been working at your hospital? Are they recouping money, or requesting additional info ( not even sure that is an option)?? curious how this is working??:)

My understanding is that Observation status is considered to be an outpatient status. It drives me a little nuts when people state that she was "... admitted to observation status", when in reality she has not been admitted at all. The patient did not meet inpatient level of care criteria or she would have been made an inpatient. . Observation is paid under medicare part b, and after deductible it covers at 80%. A medicare supplement would likely pick up the other portion. This often times comes as a surprise to patients especially when they are in a johnny, and in a bed. The hospital i work at has started giving out an observation status letter of explanation, in an effort to avoid lots of complaints when the bills arrive. It also is extremely important for the medicare patient to understand that these days are not considered under the 3 day qualifying stay rule that can enable coverage at an SNF, if appropriate skilled need is evident. At times people are in observation status for many days, we often times have to tell them that even if she was admitted, the days would not be considered qualifying days. It is all about level of care and appropriate use of resources. Hospitals are running scared because of the expected RAC's that medicare is implementing that may require hospitals to pay back funds, if audits determine that the level of care billed was not appropriate. OMG if this happens it could put hospitals out of business!!

I have requested an opportunity to shadow with a potential employer in the past- I feel it gave me a much better understanding of the expectations of the role I was looking to fill-- I would take it as a good sign- be yourself, ask intelligent questions, and decide if this is a job you would like. Good luck!

I really think it depends on what type of case management you will be doing. I have worked in acute care case management as well as an insurance company. i feel by overall knowledge about healthcare and processes has grown over the years, because you really do need to know what you are talking about when dealing with patients/ families/doctors/insurance companies/vendors/agencies etc... however, the term case management is tossed about very freely these days. I do believe in homecare, what we used to call primary care nurses, are sometimes referred to as case managers because they coordinate a variety of services. i would recommend as stated earlier going to the specialty site here, or trying the case management association for more info. I am a certified CM and have been able to work in a variety of settings, but for a long time continued to work per diem as a visiting nurse. I do feel you lose the " hands on" skills and confidence if not using them, so that may be another option. I have never heard of a new nurse being hired as a case manager, because of the need for a well rounded knowledge base. Good Luck!

If they are capable of giving out their own meds, then why do they need rehab-- I am still in the learning phase about the new MDS twists, but complex medical patients are important, and I think ADL needs are going to be weighted at higher rates. i too am not sure who are the best to take these days when there are actually choices ...sometimes there are so many empty beds, anybody looks good.

I am not sure if this would be considered fraud or not. The subacute facility I work for no longer allows patient's to bring any of their own medications. Apparently the lawyers have determined that we cannot do this ( we did in the past). My understanding of the rational is that when a patient is going to an ltc for rehab under medicare payment, the facility is required to provide for their needs,as part of their rug rates. Medications are included. I do not know how other facilities work this out,although I know they do, but we are no longer able to do so.

Is that something that can be detailed in a living will? i know I need to put my desires in writing, my husband will totally not get it. Good luck with this case. We have a resident with very debilitating MS, they were just able to extubate her , again, spouse just cannot let her go... so sad.

I really do not think case management is the place for you, at least not in a hospital or insurance environment-- case managers are totally involved with the health care industry/business, and have to be very aware of what is going on and how to adhere to these guidelines and limitations while still advocating if possible for their clients. Maybe a clinic, or community based case management position, but I would advise you to steer away from the others. Just my two cents... but there are other options out there, good luck!

I agree with a couple of the other posters- and also am sorry for your Dad- I do believe also that your step mother is the legal decision maker if no others have been defined-- i would suggest you speak to the doctor or nurse, and ask them to speak to your step mother about positive feedback, and the assumption a patient can hear all that is spoken whether he can respond or not. Maybe that will get the point across to the family members that are negative, and hopefully encourage them to speak to him in a more positive manner while taking the burden off of you. Good Luck!

With the concern for RAC's, i think the weekend staffing will be increasing. The concern being that medicare can review for appropriate level of care in retrospect and recoup monies if not appropriate. I am only per diem in case management, work about a weekend/month , but they are likely to increase the weekend expectation which is tough if you did not sign up for it..

I was fortunate to work from home- I started with the company, out at the hospital in the mornings, then in a cubbie in the afternoon and hated it-- then, the company decided they would save significant money setting our department up from home-- so I lucked out! I know some other companies including Aetna, and Anthem base their hospital case managers, meaning Utilitation Management RN's, from home after a period of time. UM was difficult from me at first so be aware- you reallly are not expected to be a patient advocate. You are an insurance company advocate--the idea is the save the company money! bottom line! Much more a business model, although even acute care case managers have to review for level of care these days. You must determine if the patients meet acute level of care criteria, if not , they need to be discharged or the hospital may get a denial. in the subacute area the patient gets the denial. i was sometimes very conflicted. I also worked in dissease management briefly-- the job itself was ok, alot of teaching to members over the phone. the problem is you are judged on how many people you call. If the program you work for has a lot of working age folks, you may have to work off hours to reach people. In terms of finding the jobs, Try career builders, or other search engines. I also have recruiters calling me fairly often-- good luck!

You didn't mention what type of case management you will be doing? I was home based for 6yrs working for an insurance company- I would go to the hospitals in the morning to review for utilization purposes, but then from home to contact Md's and smaller outlier hospitals--my advice to you is to get to know you peers. Get their home numbers and reach out during the day, be it to just say hello, or to discuss difficult cases--I loved working from home, and it worked for me and my family at that point in my life- but sometimes it can get lonely and you can feel a bit isolated, so if you can make contacts, and friends with your coworkers it can help when you have some down time and are wondering what is going on out in the world! Good Luck in you new position.

No matter what your role, if you are thoughtful and smart, and always do what is best for the patient, you will do fine..(.if that means asserting yourself with a doctor or family member so be it-you are doing your job):)

Nursing 101 Yesterday 01:11 AM written by Copper4 | 1 Comments Print Email Follow I have found myself frustrated of late because I think bedside nurses may be missing some basic care elements-- I have not been a bedside nurse in the acute care setting for a very long time, and realize that the tasks and responsibilities are mutliple. I generally have the utmost respect for bedside nurses. Most of my clinical nursing was in homecare, but this was after a good 5 years of cardiothoracic nursing in an acute hospital setting. I now work as an acute care case manager. Often times have to place people in nursing facilities upon discharge because they have become debilitated while in the hospital's care. The other day I was working on the weekend, My role entailed reviewing for appropriate level of care. My responsibility was to review observation patients and new admits and assure that the level was appropriate. I came upon a 92yo woman who had fallen while getting into her car, she did not meet acute level of care criteria for admission. She was placed on observation status, thankfully had not broken anything but did require a short stay to make sure all was ok--- she was chronically on coumadin and therefore the fall did cause her to look like she had been through the mill with lots of ecchymotic areas. The dilemma was what to do with her upon discharge. This woman wanted to go back to her independent living apartment with homecare. I asked the nurse to walk this patient to better determine her functional status. The nurse essentially told me she did not feel comfortable walking this woman and she would need to wait for a physical therapy consult.. I asked why and the nurse told me she was concerned about the liablity. i asked what about DVT's, ileus's, pneumonias? all the adverse complications of immobility... no response, not willing to take the risk. I called the PT and asked for an evaluation, the next day found out she walked 300 ft with her walker and supervision. This has become a bit of a pet peeve of mine. I have also seen demented patients who have sitters with them, so that they will not climb out of bed. However, the aides assigned to them do not bother to get them out of bed. I worked as a sitter in college, and totally cared for the patient, got them up and moving if able. Tried to get them tired so that they would sleep peacefully. Perhaps the person wouldn't be climbing out of bed if they were given the opportunity to get out of bed! Isn't it basic nursing to get the patient moving? Get the lungs ventilated, get their blood flowing, bowels moving etc... or are we so concerned with potential law suits that nobody wants to risk it? Maybe I am just old...

I have worked alot of homecare and i agree with the consensus... you need to gain experience and confidence in an institutional setting first. The strides you can make caring for patients in either a hospital or ecf will lead you to be a better, more organized nurse, that can think on your feet. In homecare, you do not have anybody to immediately ask for help. If a patient is having a strange symptom, or a problem, you need to have the ability to differentiate between urgent, and emergent. Good Luck whichever path you choose to follow.:)

In case management I need to know patient's insurance coverage and advocate based upon needs, and resources available- I try to treat all patients with respect and dignity-- having said that I have become much more conservative as I grow older. I recently had a patient come to the ER, he had recently come from Vietnam and had a dx of malaria. I am only authorized to provide $75.00 for medication if a patient has no other means of obtaining it...he could get the other meds at Walmart but one particular med was twice my authorized amount.. the doctor yelled at me, and I explained that was all I could do, the patient needed to pay for the other portion of the cost... the pharmacist contacted his supervisor and had the med paid for and provided by the hospital. My issue is that this man chose to come to America, and apparently came without a dime in his pocket? I have a friend who had to sponsor her mother to come from Poland, that required her to prove she had significant funds to provide for her family member to come on a long term visa...apparently this is not across the board. I find myself now wondering why this is acceptable behavior.. America is a melting pot, but is it our responsibility to care for people who chose to come without a means of supporting themselves? I guess I digress. The medicaid issue has just recently hit me on a personal level. My spouse is heavy, and has really not been able to lose weight the traditional way (less calories in, more output) , I think he may benefit from gastric bypass or banding, even though the thought of it scares the hell out of me... My SIL had the procedure about a year or two ago, she had been unemployed for > than 2 yrs and because she has young kids qualified for a state subsidized program. Oh yes, her husband has also been laid off for quite some time now- guess what, her procedure and all associated Md/ counseling visits were covered. I work for a nonprofit organization/ self funded, and they do not pay for bariatric procedures. I am glad for my SIL, glad it was successful. My MIL actually offered to pay for my husband to have the surgery, but having worked in insurance I am aware that this could be a very awful situation. If a procedure is not a covered benefit , then any and all subsequent issues related to that procedure are also not covered. I cannot let them pay for such a thing, knowing about potential complications. Anyway, how come this is fair? I work, my husband works, and we are insured and cannot get the care we need, but my inlaws can on medicaid- this is a situation when it kind of just does not seem fair. Thanks for allowing the vent...

I guess purchasing the "hardcover" from a favorite author rather than waiting for paperback, or going to the library, dinner out, long weekend away...

..."The doctor is much more likely to give you want you want (need) if you ask in a calm and organized manner. Get your ducks in a row and have the answers to his questions before you page him." Good advice, it is all in the presentation!

I think it depends on whether or not you want to work hands on with patients or not--I worked as a homecare nurse for years, and feel that was actually my original niche-- then moved on to Adult Day Care, and then to Case Management- I have also worked for an HMO, if you want little patient interaction I would recommend the insurance company route, plus the benefits were great, much more corporate level in terms of 401K etc... I do think any good nurse needs at least a few years of solid med-surg experience in a hospital setting to actually learn what they are doing. Homecare is not the place to be if your assessment skills are not yet fine tuned...all sorts of possibilities out there.:)

...way back in the olden days I worked as a nurse's aide-- this was before any certifications were required, I was 16yo and needed a job I could walk to -- the woman training me at the ecf told me to treat the patient in the bed as if she were my mother...she would want to be clean, and dried, covered to be warm, and to maintain privacy and dignity,etc. and treated generally with respect--I have never forgotten that advice!