Advocating for patients, coordinating care, finding resources, educating patients and family members, and facilitating services its all part of RN case managers daily duties.
Inpatient case management is the hub of everything that is going on with the patient, says Ceil McElvaney, RN, manager of case management at Ocean Medical Center in Brick, N.J. The main case management function is to coordinate and facilitate care of the patient.
Case managers enjoy helping guide patients through the continuum of care and getting them the services they need, adds Rachelle Schwartz, RN, MA, CCM, director of case management at the Hospital for Special Surgery in New York.
They ensure the patient is receiving the appropriate care at the appropriate level, and they are liaisons with the rest of the team, Schwartz says. With an increasingly older patient population and with more patients covered by managed care plans, she reports a greater demand for hospital case managers.
Geraldine Ryan-Gardner, RN, case manager at Nyack (N.Y.) Hospital, indicates that the role has grown since she became a case manager in 1995. Our role has become much more an integral part of patients being in the hospital, Ryan-Gardner says.
Changes in healthcare at the payor and provider level have led to a growth of case management during the past 10 to 15 years, adds Cathy Mullahy, RN, BS, CRRN, CCM, president of Mullahy & Associates, a case management training and consulting firm based in Huntington, N.Y. There is a growing need for resources and a shrinking pool of dollars. People are living longer with complex conditions.
The advent of healthcare reform and incentives to reduce rehospitalizations likely will boost the ranks even further in the years ahead and create more opportunities for nurses. Theres great demand for case managers to help the patient navigate the system and the continuum of care, says Keera Ferreira, director of case management and social services at Clara Maass Medical Center, a 445-bed facility in Belleville, N.J. Ferreira says she expects hospitals will add case managers to work 24/7, especially in the ED.
Hospital Case Management
Hospital case managers also often provide utilization review, following patients from admission to discharge to make sure they meet inpatient criteria and to plan for discharge, coordinating with the patient and family.
Case managers are vital to keeping the facility viable, Ferreira says. You have more and more complex patients navigating the system. You have patients who lost insurance, and we find what programs are out there for them. You have to be innovative and creative to get this patient to a safe disposition.
Case managers work collaboratively with the insurers, the interdisciplinary care team at the hospital and staff members at the receiving agencies, Schwartz says. McElvaney adds case managers help patients understand their health-insurance benefits, which will affect the plan of care. About 80% of patients at the Hospital for Special Surgery require assistance with discharge planning.
You have to juggle so many things what the patient needs, the benefits and the resources in the community they are entitled to, Schwartz says. That can be challenging and very rewarding.
Caseloads vary from 12 to 15 patients at Nyack to between 25 and 30 patients at the Hospital for Special Surgery. The roles are typically the same in small and large hospitals, Mullahy says, although changes are in the works, with a focus shifting toward ensuring patients receive the care they need after discharge to avoid readmissions.
Case Management Careers
Most hospital RN case managers transitioned into a case management position after years as staff nurses. Hospitals typically provide some orientation, hands-on instruction and annual updates to help nurses learn the job and stay current.
A good nursing background with clinical expertise helps nurses understand the appropriate level of care, Ferreira says. She looks for nurses who are assertive and can work well with patients, physicians and other members of the healthcare team.
Mullahy adds that nurses with experience in diverse practice settings have the professional background to be good case managers.
It is not for the new kid on the block, Mullahy says. Most employers are looking for seasoned professionals.
Case managers say it takes a nurse about a year to feel comfortable in the role. Ryan-Gardner joined Nyack after two years as a case manager for a health plan, which she found beneficial in understanding insurers positions. Working with patients undergoing different procedures and with various diseases has broadened her knowledge base.
It exposed me to a variety of nursing that I otherwise wouldnt have been exposed to, Ryan-Gardner says. Every day, I learn something new.
Mullahy has written a book, The Case Managers Handbook, which serves as a resource, and she offers case management courses through Nursing Spectrum. Nurses can take courses online at http://ce.nurse.com/Case-Management.
The Commission for Case Management Certification and the American Nurses Credentialing Center offer case management certification. Nurses need a license in every state in which they work with patients, Mullahy says.
Other Case Manager Opportunities
In addition to hospitals, home care agencies, rehabilitation facilities, insurers and other entities hire case managers.
Everywhere healthcare is delivered or paid for, thats where you find case managers, Mullahy says. In addition, she reports a direct-to-consumer model in which people could contract with an experienced case manager to help them find the services they need.
One patient at a time, you can make a difference, Mullahy says. When you do the right thing for the right reason everyone wins.