Case Management Nursing

My Specialty

Case Management Nursing

A multi-discipline approach

By Keith Carlson, RN, BSN
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Shannon Brown, RN, MSN
Nurse Manager for Case Management Dept., Maternal Child Case Manager
Hoag Memorial Hospital Presbyterian, Newport Beach, CA


How long have you been a nurse, and what is your career history?
I have been a nurse for 13 years. After earning a B.A. in Child Development, I was accepted into an entry-level Master’s in Nursing program at Samuel Merritt University, earning both an RN license and MSN. I knew that I wanted to focus on pediatrics as a specialty, and I made case management the focus of my master’s program.

I began my career as a pediatric oncology nurse at Lucile Packard Children’s Hospital at Stanford and took on the role of pediatric oncology case manager. Later I worked as a bone marrow transplant coordinator at Children’s Hospital in Orange County, and then came to Hoag Memorial Hospital Presbyterian as a maternal child case manager five years ago.

What brought you to case management as a specialty?
Throughout my career, I have always been drawn to looking at the big picture. As an oncology nurse, you’re always thinking beyond the immediate shift, taking the patient’s whole life situation into consideration. This also applies with case management, so it was a logical transition. Also, I love family dynamics, so I gravitated naturally into case management. You’re never treating just the patient, and that is challenging and gratifying.

Can you explain any special certifications or training that a nurse needs to enter this area of nursing?
You can enter case management from any aspect of the nursing profession. You can be a bedside nurse and evolve into the position, and you learn as you go. In my master’s program, I greatly valued the education that focused on the financial aspect of healthcare, especially since most nurses don’t usually have exposure to this type of education. A certification in case management helps you to understand workers compensation, insurance and other important issues.

What is most challenging about your work?

I think the hardest part is the limited availability of resources in community settings. You want to give your patients everything under the sun, to provide the best care for their individualized needs, and you have to be resourceful in how to do that. For instance, some areas have a lack of outpatient mental health services, and some patients end up in acute care when an outpatient setting would be best for them. So you do your best.

What keeps you coming back to work every day? What feeds your spirit?

Case management allows me to be a part of every step of the patient’s care. I help the insurance company to get the whole picture, and I ultimately prepare the patient and their families for discharge. It’s very gratifying when you hear from the families that it’s going well. I also see this healthcare team working together and the positive impact they can have on patients’ hospital experience.

How has case management changed, or how do you see it changing in the future?
Healthcare reform and the healthcare marketplace are in a state of complete and utter change. It is an exciting time, but we have to be focused and ready. The continued advancement of technology and of healthcare delivery is also in flux. We used to do case reviews on paper, and now everything is electronic and digitally-based. The way that we work has completely changed. Services were once primarily offered within hospitals, whereas now much of healthcare delivery is in the outpatient setting. There is also a greater impact on patients’ ability to understand insurance benefits. We have a big stake in the patient truly understanding the system, which is changing very quickly.

Bearing HIPPA in mind, is there a story or anecdote about a particular patient or situation you would like to share?

As a maternal-child case manager, you have moms that come in unexpectedly and deliver preterm babies. They’re simply not ready for the experience, so we support them through the rollercoaster of the NICU. When they’re ready to be discharged, we assist them through that process, making arrangements to fulfill the many needs they will have once they’re back in the home environment. Afterwards, they return to the developmental clinic at six, nine and 12 months, so it’s very gratifying to get feedback on how the baby and parents are doing along that continuum.

What are your current professional goals?
I would like to stay aware of Medicare changes within the new healthcare reform law, and its impact on patients. I also plan to participate in frequent opportunities for continuing education and professional conferences where I can learn new skills and network with other acute care case managers. In five years I hope to receive my 10-year Hoag Recognition Pin, because it’s nice to have that longevity in one facility. To stay in one place has great value, and Hoag is a great place to be!

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Jennifer Savoy, RN, BSN

Jennifer Savoy, RN, BSN
Zenith Insurance
Woodland Hills, CA


How long have you been a nurse, and what is your career history?
I’ve been a nurse since 2007. I was trauma-trained at Cedars Sinai, worked in the ER, and then came to Zenith in 2010.

What brought you to case management as a specialty?

I wanted the opportunity to have a normal work schedule and have more time with family. This is my first experience with case management.

Can you explain any special certifications or training that a nurse needs to enter this area of nursing?
After one year at Zenith, our nurses pursue CCM (Certified Case Manager), through the Commission for Case Management Certification which is the gold standard around the country. Zenith believes strongly in having nurses pursue this certification as many jurisdictions require different certifications for workers’ comp and other specializations within the field. It is the belief of Zenith that we will be ahead of the curve; therefore we have this standard in all jurisdictions for our company.

What is the nature of Zenith’s case management work?

Companies pay a premium to Zenith for us to handle workers comp and other claims. We underwrite and service each specific insurance policy, and we use evidence-based practice to make sure our clients reach the goal of returning to full function and normal lives. We work as patient advocates, and we have excellent relationships with the companies that we serve, as well as the workers to whom our role of patient advocate is clearly communicated.

What population do you work with?
We have workers’ compensation cases, clients with spine and back issues, crush injuries, rotator cuff tears, and an assortment of other orthopedic issues. We specialize in agriculture, small businesses, dental, manufacturing and hospitality, so there are a variety of injuries seen in this role.

What is most challenging about your work?

In any area of nursing, language, culture and educational barriers are very common. When we are handling a case that’s in litigation, we sometimes have no access to the involved workers in order to facilitate the care that’s needed, and that can be a challenge. There are also frequent changes in law and labor codes that we have to keep abreast of.

What keeps you coming back to work every day? What feeds your spirit?
I find the same things that drew me to the ER and trauma still apply to this job. Every day and case is different, and there’s no room for boredom. Everything has its nuance and needs to be handled differently. It may appear monotonous but it truly is not.

The level of autonomy that we have is wonderful. We receive excellent training and certification, and critical thinking is emphasized. In the hospital setting, it’s still a patriarchal system, and we are dependent on doctors and the “chain of command.” The beauty of case management is that it’s my individual job to understand the mechanism of injury, evaluate exam and diagnostic findings, and put together a plan that will bring the client back to full functional status. Although we have a medical team, my autonomy in this regard is very clear.

How is the field changing?
Does the aging of the American population have a bearing on these changes?
Workers’ compensation is always changing because it’s state-based and alterations are made based on legislation and regulation. Every state is different. The aging workforce is also a concern. Although older workers don’t get hurt as much as younger workers, when they do sustain an injury it takes more to put them back together. The increasingly obese American population also impacts recovery time and the severity of injury.

Bearing HIPPA in mind, is there a story or anecdote about a particular patient or situation you would like to share?

I can think of a crush injury case to a worker’s hand. He underwent surgery and was about to start therapy. When the bandages were unwrapped at his first therapy appointment, the wound was infected, so the doctor gave him oral antibiotics. I looked at the report and thought we should jump on this infection and treat it more aggressively, but the doctor was not convinced.

Two weeks later, it was still not better, and I pushed for a culture and suggested a course of IV antibiotics. The doctor again resisted my recommendations. At the next appointment the wound was worse. The patient now needed hyperbaric oxygen therapy, and time was of the essence. Within three days, I had an MRI done, a PICC line placed, an appointment with an infectious disease specialist made, and the hyperbaric treatments started.

Even though the doctor initially ignored the advice of someone who was “just an insurance nurse,” eventually I prevailed through persistence and clear and direct communication. The situation eventually resolved well and that was very satisfying for me.

What advice would you have for nurses or student nurses wishing to explore case management as a career option?

Many nurses see case management as the place for burnt-out nurses who don’t want to do hospital work any more. One of my colleagues at the hospital once said, “You’ve gone over to the Dark Side” — and this is such a misconception! Case managers, whether they work for an insurance company or not, focus on patient advocacy, and we look for people with good critical-thinking skills. It’s a job for anyone who wants to help others and truly make a difference. 

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Did You Know? CASE MANAGEMENT NURSING

Overview  As case managers, nurses work closely with members of multiple disciplines in order to assure that patients receive needed care, appropriate transfers, referrals and ancillary services. Coordinated case management can improve outcomes, lower costs, and facilitate improved communication among providers, patients, families, and facilities. Nurse case managers also serve as powerful advocates for patients and their families.

Your Workplace  Some case managers provide direct nursing care combined with case management (as in the example of a visiting nurse), while others provide strictly case management while perhaps overseeing a group of nurses providing care to a specific cohort of clients (such as retired mine workers). While certain case managers work in the field visiting patients at their homes and providing ongoing assessment and oversight, others (such as insurance nurses) may provide their case management services solely over the telephone and via computer.

Some scenarios where a nurse case manager might be employed:
    Maternal-Child/NICU: Helping families to navigate premature birth, NICU, and the confusing and challenging months after NICU discharge.
    Hospice: Assisting patients and their families when a patient is placed on hospice and is planning to die at home with the support of family and the hospice team.
    Home health: Working for a visiting nurse agency case managing a number of home-based patients living with chronic or acute illness.
    Private or public agency/company: Managing the care of a number of patients who all share a similar diagnosis or condition, such as retired mine workers, or individuals with brain injuries, HIV or Hepatitis C.
    Hospital unit: Managing home health referrals, skilled nursing facility transfers, and insurance issues for multiple patients on a Med-Surg unit. Case managers on oncology units, for instance, coordinate chemotherapy, radiation, medical visits, transportation, and other important aspects of patients’ care.
    Insurance company: A nurse case manager for an insurance company manages the care of individuals covered under plans administered by that company.
    Long term care facility: Managing and coordinating multiple aspects of patient care, including admission, ancillary services, transportation, referrals and discharge.

RESOURCES

Certifications and Trainings:
COHN: Certified Occupational Health Nurse Specialist (www.abohn.org)
CDMS: Certified Disability Management Specialist (www.cdms.org)
CRRN: Certified Rehabilitation Registered Nurse (www.rehabnurse.org)
QRP: Qualified Rehabilitation Professional

Web Resources:
American Case Management Association: www.acmaweb.org
Hospital Association of Southern California: www.hasc.org
American Nurses Credentialing Center: www.nursecredentialing.org
Center for Case Management: www.cfcm.com
RN Case Manager: www.rncasemanager.com
Commission for Case Manager Certification: www.ccmcertification.org
Case Management Society of America: www.cmsa.org

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Keith Carlson, RN, BSN, is a registered nurse, writer and blogger. He writes for a variety of nursing and health websites, and has been included in several nonfiction nursing books by Kaplan Publishing. He is editorial contributor to BlackDoctor.org. His own blog can be found at digitaldoorway.blogspot.com.  

This article is from workingnurse.com.

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