starting a case management department

[jcol1460]

Hi there, I'm looking for some feedback and suggestions.

I'm currently a psychotherapist (MSW) and will be starting a nursing program in January. I work in a non profit substance abuse treatment center (outpatient, residential treatment, and medical detox services). Through my time there, I have been able to identify needs this agency has for client care. They currently do not accept insurance, but with the funding limitations we are starting to experience (South Florida area. We're being managed by a for profit managing entity now, as are all other publicly funded agencies) there is a need to start accepting insurance in order to increase funding streams available. This managing entity is increasing their focus on discharge and aftercare planning (even though the M.E. has pretty much tied our hands on how we can discharge plan with our clients, but that's another story entirely) and is causing a lot of changes in how we approach every level of care. My employer and I will be sitting down in the coming weeks to discuss how I can utilize my current skills and increasing knowledge in the nursing field with their needs. Since we don't currently have utilization review or case management/discharge planning departments, my aim is to work on opening up one if not both of these departments.

My questions are as follows:

1- What nuances should I be aware of to present during this conversation which will help or would be necessary to make either department successful?

2- What software would the agency need to utilize in order to have a level playing field with the insurance companies/managing entity? We're public funded so think along the lines of DCF, courts, dept. of corrections, etc...

3- What would be a reasonable pay request? Something to keep in mind, my agency underpays for the field, so I couldn't ask for what would be normal in a hospital setting.

4- Anything else you may suggest.

I appreciate and welcome all feedback.

Thanks

[jcol1460]

Anybody there???

[SummerGarden, BSN, MSN, RN]

You might want to try the Entrepreneurs in Nursing forum rather than this one. Also, although you want to become a nurse, you are not one. And so, nurses should not be working under you or answering to you or any other non-nurse if he/she is working under his/her professional license.

[Debi Fischer]

I agree with MBARNBSN. You may be putting the cart before the horse. I can talk because...I am an RN who got an MSW and finally a ...BSN! That being said, there is a whole different mentality that goes with nursing vs social work which I am still learning.

I think that you are headed down the right path doing the combo, but it will take at least 4 semesters to finish nursing school I guess.

Then pass your boards and get a CM certification.

Just enjoy the ride because it will be bumpy!

Nurses have a different mind set from social workers, you will have to learn to wear 2 hats, take one off, depending where you are and put the other one on. Of course, once you finish nursing school, and become an RN, you will forever be a different person, and think differently. I think you will see a bigger picture than with the MSW alone. It is a brain/game changer.

[jcol1460]

Nurses have a different mind set from social workers, you will have to learn to wear 2 hats, take one off, depending where you are and put the other one on. Of course, once you finish nursing school, and become an RN, you will forever be a different person, and think differently. I think you will see a bigger picture than with the MSW alone. It is a brain/game changer.

Ain't that the truth!!! I've been quickly figuring that out over the last two semesters taking pharm and a nursing critical thinking skills class.

I am concerned about the cart before the horse thing, and I am very aware that I can't supervise anybody at this time. However, it is a ginormous need in my agency and as a MSW I am qualified to do case management, just in a different way. These are the types of things I need to be able to speak about. How is a social worker approach to case management different than a nurse? From my limited experience working with hospital social workers/case managers, I personally didn't notice a difference. I'm sure there is one, I just don't know what specifically.

[SummerGarden, BSN, MSN, RN]

The nursing focus can cross into a social service side, but as an MSW you know that a nurse without a solid background in safety evaluation or counseling will not provide the same services to a client's social needs as you would, correct? And so, when a social worker provides a wheel chair for a patient to go home (for example), it is similar to a lay person who does not understand the why, but the how and so the patient is not being best served. With that said, an optimal use of nurse case managers in any setting is to use them clinically more often than not!

A nurse case manager's focus should not be social services except to identify that there is a need for social services and to refer to proper people (that would be you right now). The nurse should focus on why a patient needs equipment, why a patient needs to be placed in a particular setting, and why a patient needs to continue to receive medical treatment in any setting. The nurse should also communicate these needs and get orders from health care providers, get authorizations from insurance companies, coordinate medical arrangements through vendors and providers, and discuss these issues with patients and families/caregivers through educating patients and families/caregivers. Does this make sense? If not, it will make a world of sense once you are working as a nurse case manager.

I used to work as a social worker case manager without an MSW. I agree with the above poster. My role as a nurse case manager is night and day different than my days in social services. I understand and have a scope of practice that better serves patients medically. Medical Social workers think that he/she knows what is going on, and being on this side of the fence now, I can see how many times it is easy for someone who has no educational background in medicine or nursing to have poor judgment and to mistakenly think that he/she knows what is going on medically when he/she has no clue!

For instance, I know a very good Medical Social Worker who assists cancer patients. She thinks that she knows just about everything about Oncology because the doctors and nurses talk to her often and share knowledge. However, she is what we nurses call "having enough knowledge to be dangerous". In other words, she has so many holes in her understanding because she has no medical education, that she does not have a clue and unfortunately she does not know that she does not have a clue as to what is going on. She does not know that parroting the doctors and nurses is not the same as understanding medicine.

[Debi Fischer]

I'll give you an example. Do you read the doctor's admission notes and know what the medical issues are? Do you read the ER notes, or the transfer notes from the Dr? Or do you just look at the diagnosis? You need to apply the broad strokes to any case. There may be underlying medical issues that need to be addressed.

[SummerGarden, BSN, MSN, RN]

I'll give you an example. Do you read the doctor's admission notes and know what the medical issues are? Do you read the ER notes, or the transfer notes from the Dr? Or do you just look at the diagnosis? You need to apply the broad strokes to any case. There may be underlying medical issues that need to be addressed.

Nice post..... :)

OP: You can tell your employer that Social Workers do not have the medical background or education to decipher medical needs. Nurses can best serve us in this way. For example, social workers can be given information and told things by medical staff, but social worker do not know enough information (do not have a medical background) to question that information.

A good example: Both a social worker and a nurse will know that the patient's medical condition dictates if an insurance payor will cover the cost of the wheelchair. However, a social worker is told by a patient's family and physician to order a wheelchair and may do so based on what information he/she is told. A Nurse can be given that same information, but will independently identify the medical need for the wheelchair. If there is no medical need, a nurse will notice right away and educate the patient, physician, and family that the patient will need to pay out of pocket for the cost of the wheelchair. Whereas, the social worker will end up fielding the call from an angry patient because he/she will be billed for a wheelchair that was not covered by insurance.

As for UR/UM the same applies. Nurses with clinical backgrounds can read charts and assess patients. We understand information to provide insurance companies that is pertinent to care. Guess who provides authorizations from insurance companies to cover medical services? Physicians and nurses. Ergo, social workers are not qualified to perform this role and they are not qualified to directly supervise RNs in this role either.

[jcol1460]

I'll give you an example. Do you read the doctor's admission notes and know what the medical issues are? Do you read the ER notes, or the transfer notes from the Dr? Or do you just look at the diagnosis? You need to apply the broad strokes to any case. There may be underlying medical issues that need to be addressed.

Actually, yes, I do read the nursing and physician assessments. I will say though, that the medical issues I encounter are all pretty similar as they are results of drug and alcohol use. It is rare for us to run across major medical issues as clients are screened prior to entering to make sure they are within safe medical management to be in treatment at that time. Our detox unit is the medically managed unit, but once again, if there are major medical issues, clients are sent to the hospital first.

As far as having just enough knowledge to be dangerous, I wholeheartedly agree at this point. I'm worried about getting in over my head while I'm trying to get through nursing school. If I have it my way, I wouldn't work on opening up these departments in earnest until AFTER I've completed at least the ASN portion of my nursing school (I do plan to go immediately into a RN-BSN bridge program once I've passed the NCLEX). But, this conversation will occur before this happens as it will also be tied into a compensatory package where (hopefully) my employer will help me with the cost of school. The discharge planning that is in the greatest need now is social work oriented more than nursing oriented, but the need for nursing oriented case management is present. So this could be something I could 'grow' into as my knowledge increases.

Thanks all of you for your input and suggestions. You have definitely given me some points to ponder. Happy holidays to you.

[nurseprnRN, BSN, RN]

Also, although you want to become a nurse, you are not one. And so, nurses should not be working under you or answering to you or any other non-nurse if he/she is working under his/her professional license.

I, too, used to feel this was a nonnegotiable item until we solved this problem at one company where my boss was not a nurse. We agreed that she was my boss in terms of policy, company rules, scheduling, and the like, but she never, ever questioned or directed anything that had to do with nursing or my nursing judgment.

This same model worked well for a friend of mine, a nurse who ran a clinic and supervised physicians. She ran the clinic, scheduled, hired and fired, wrote and maintained policies, etc., but never involved herself in medical issues.

Many MD offices work this way too-- the MD owns the practice, but cannot mandate nursing practice.

Separating administrative from professional realms is perfectly possible and often advisable.

[elkpark]

I'm sure I'm missing something here, but wouldn't it be a whole lot easier and quicker for your agency to hire one or more RNs with chemical dependency and case management experience??

[jcol1460]

I'm sure I'm missing something here, but wouldn't it be a whole lot easier and quicker for your agency to hire one or more RNs with chemical dependency and case management experience??

While the answer is clearly yes, non profits very often don't do what is easier or make a whole lot of sense 😋.

Not to mention, I doubt my agency would pay what an experienced case management nurse could command in this field. I think the benefit I provide is I know their system well and already know what the needs of our clientele are in the social work realm. My nursing degree can provide another level of understanding which supplements current knowledge. The nursing staff there really have very little idea of the therapeutic needs of the client as they focus on the health/wellness needs which are within the scope of their practice.