What's your day like working as a Psych RN case manager? (Community based especially)

  1. Hello,

    I'm curious about case management as a potential next job in mental health nursing & there is currently a position that is mostly clinic based that I'm looking at. Does anyone work in such a setting and what is your typical day like? Do you feel it is much safer than working on an acute care locked facility?

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    About jo716

    Joined: Jul '07; Posts: 27; Likes: 3


  3. by   EverLearningLPN
    It wasn't clear to me if you have ever worked much with psychiatric patients prior to being interested in the two positions. I know case management is different than the nurse taking direct care of them but some of these things I will share may give you some insight that may prove helpful in one way or the other. Maybe others will comment that can better answer your question specifically. I imagine you will most certainly need to interact in different situations with them and it can get scary to put it mildly.

    I worked in a nursing home where other nursing homes would not take our patients because of their behaviors. I took care of psychiatric patients from all walks of life from court judges to those who had been living on the street to airline pilots who were middle aged to elderly. You name it. It was a locked facility.

    As a floor nurse in LTC with those prone to violent outbursts where body slamming a nurse or breaking their nose while attempting to provide care was not exactly every day but not uncommon, here are some tips. By the way I loved it but now work in pediatric home health.

    Depending on their diagnosis and current state these can be extremely beneficial. Sounds too simple but I found to be cardinal rules.

    ALWAYS know where your head is in relation to their hands, elbows, knees, feet, head.
    Speak calmly and keep your voice level no matter what. Talk a bit slow to ensure they are able to process. If they start talking fast that is a bad sign.
    Smile often. Smiling works really well most of the time unless they are very agitated.
    Don't touch unless you take their temperature and by that I mean, ask them how they are doing. I can't stress that enough. If you approach them introducing yourself then go into your spill, you are courting danger. You want a good phrase or sentence response. Look at their body language and overall demeanor. If you don't get much of anything in their first response , ask another question. By the second question you should know how to proceed.
    If they state a complaint or particularly if they interrupt you to make a complaint, pay close attention. Staff may have given them the run around all day or made promises just to get their short term cooperation. You may be the number tenth time they have tried to talk to someone to get a resolution. Address it giving them your full attention. They have difficulty typically remembering or putting what they want to say together so it can be very frustrating without getting no where with the 9 other people before you.
    Your instincts will help you. Trust your gut! If you are feeling fearful, be aware of why and not just telling yourself everything will be fine. Fear might be your first and only clue before something happens.
    The more you get to know them you will be able to read them better but even when you know them, never assume as that can change dramatically.
    They all have what I call currency. Find out what theirs is. Staff know. It is that one thing that makes their world go round.
    Don't put yourself anywhere that others can't hear you shout for help.
    Other psych patients close by can stimulate each other and a fight can break out before you know what has happened. There doesnt have to be a real good reason. A small bump into someone by another patient can erupt into violent chaos.
    Don't overdo it trying to reason or explain something to them if they are too agitated to process it. Focus on keeping them steady and disarming the situation.
    If someone is prone to violence or agitated never try to approach them without back up. They don't have to be standing right there but someone needs to be paying attention and gauging the situation and ready to step in.
    Once it is determined they must have a shot, there is no going back and forth. The situation requires everybody involved be on the same page and focused and everybody knows their part. Some people have shorter fuses so it is best to watch them closely and not give as much time.

    Anyways, those are what I would call the dirty dozen. You will be fine.
  4. by   EverLearningLPN
    Sorry! I am new to the site. My last comment was not intended to have question marks. I had tried to post an emoticon. All the best to you.
  5. by   Davey Do
    I worked with a couple of Community Mental Health Clinics and Case Management was merely a small portion of my duties, jo.

    At the one Community Mental Health Clinic where I was not an Administrator, in addition to the Case Management duties, I set up and ran two medication programs, administered IM meds like deaconates, was a mandated follow up agent for the local State Mental Facility, a Pre-Admission Screening Agent for the southern portion of the county, worked in the Crisis-Stabilization Unit, gave two-hour lectures twice a week to court-ordered clients, and other duties as assigned.

    The majority of the case management duties was mostly monitoring the client's mental health status and providing resources for identified needs.
  6. by   jo716
    Every Learning LPN, Thanks so much for all your insight and tips! I have actually been working in a locked psych facility for the past 2.5 years now and I totally understand all the things you've described though there's some useful info I can apply as well that's new to me! The intensity and high risk for violence is the main reason I want to step out of acute care and work in a community setting more or in a safer position which I imagine case management would be. I would like to still have some patient connection though and so I'm looking for a good middle ground. Thanks again!
  7. by   jo716
    Davey Do,

    Wow that's a lot of stuff you did! Would you say that patients in the outpatient setting were generally more calm and stable compared to inpatient patients on average? I understand especially working with Crisis Stabilization or when patients are off meds or needing to change their meds or having had changed meds they might be heading towards a similar state as inpatient but once in a while is much less intense than a few days a week to daily. I'm curious what those lectures you gave were about? What job was that related to exactly? And do you have any tips on how I could get into a case management position? Seems like most jobs are looking for people already experiences. Thanks a lot!
  8. by   hrnurse
    Psych case manager jobs can vary widely . If it's for an insurance provider for example, the duties will differ from working at a clinic or agency. Be prepared to wear many hats, not always nurse related. You may help with housing, vocational, substance abuse, etc . I spent at least 1/3 of my day filling out housing applications for pts and helping them collect social security checks. Prepare for pts to go missing, not show up for appts, be noncompliant with meds, and be very high acuity. I don't mean to sound harsh but some of the pts can suck you dry . And are quite manipulative. Prepare for hospital discharge teams and housing directors to blame you, the case manager, for everything . I'm being honest . The pay is low, the demands are very high, the turnover is frequent. One agency paid the nurses 30k a year .

    I will say if you can work in that field for a while, you will have an excellent experience in public health and make sure to highlight those skills on a resume. You'll have insight that nurses just working inpatient might not have .

    Is it safer than inpatient? No. You're often alone with a pt with no back up. You rely heavily on deescalation if a pt is agitated . CM's were assaulted and even threatened with death .

    You will see the truth of community systems in shambles. You'll witness hospitals discharge unstable pts back to the community only to find out that the housing director evicted them (even though everyone is supposed to be on the same team). You'll witness homeless shelters turning away applicants , in fact you'll see some shoddy shelters with problems such as bedbugs and reports of assault and rape. You'll see pts use social security money to buy drugs and remain homeless. Youll see the many problems with the crisis line and wonder where to place someone who is suicidal when theres no vacancies . You'll never finish all the charting and be ready for audits .

    Where you work as a CM may be very different. This may be worse case scenario, but be prepared just in case . The positive is, you will help those wanting help, and you will develop nerves of steel .