First, let's start with an official description of what case managers are expected to do:
The practice of case management is a process that manages client wellness and autonomy through advocacy, communication, education, and the identification and facilitation of services.
To obtain optimum value for clients and reimbursement sources, case managers identify appropriate providers and facilities across the continuum of health care and human services while insuring that available resources are timely, cost-effective, and efficient.
How does this help? Why are we necessary?
The benefits of case management accrue to all participants in the process. Consumers gain an advocate and emotional support. Physicians and hospitals have complex cases facilitated. And payers' costs are reduced while their customers are retained.
How does this translate into the workplace?
In the current position I'm in, I do utilization review (UR) for insurance companies. Say you recently had a pap smear that showed abnormal cell growth. You have been having irregular bleeding for 18 monhts, extreme pain with menses, you have a history of ovarian cysts. Your 55 and post-menopausal. You and your doctor determine you would benefit from a total hysterectomy. The doctor sends in the request for you to have the surgery. As the UR nurse, I would do the following upon receipt of the request:
1. Determine if the surgery is medically appropriate based on the physicians notes, history of treatment, and laboratory results.
2. Determine how long we would authorize your length of stay in the hospital (usually 2-3 days for total hysterectomy).
3. Determine if the physician's request for an assistant surgeon is warranted (usually by using national guidelines).
4. Make sure the physician is using a hospital that is contracted with that patient's insurance.
Pretty cut and dry, eh? That is only a small portion of what a case manager does and the reason why I don't want to stay in this position. Yes, I work in an office, Monday through Friday, no weekends, no holidays, bankers hours. But, how is this helping my career goals? It isn't.
What I'm going to be doing with my new job that I used to do previously:
Case management in the acute care environment (hospital-based).
1. Review the admissions to the hospital each day
2. Determine which admissions need immediate attention (usually the one's who have no insurance, indigent cases)
3. Interview the patients, determine what their needs are:
- any support at home?
- do they have transportation available when they are discharged?
- are they able to get their medications when discharged?
- have they been diagnosed with a chronic disease? What is their knowledge of the disease?
- Are they eligible for any community services?
4. Review the medical chart to determine if they need to stay longer or be discharged sooner
5. Discuss the case with the physician, what is the plan of treatment?
6. Make sure any laboratory tests, X-rays, etc. that need to be done before discharge are completed and the physician is aware of the results
7. Assess if the patient can be transferred to a lower level of care (so that $$ can be saved and acute beds can be available for new patients). If they can be moved to a skilled nursing facility or rehab unit, arrange for transfer and approval through their insurance (if they have insurance)
These are some the functions of a case manager in the acute care setting. Case managers are in many different settings: works comp, AIDS/HIV centers, Pediatric Oncology, research, high-risk OB patients, etc. Your case management goals are similar in each environment, but how you achieve those goals may be different.
Does that help? Previously to UR, I was the Case management supervisor for a workers compensation carrier. Having a background in med-surg, ICU, home health and discharge planning has made the transition easy for me.
I promote case management because it still utilizes those skills we have from our days of bedside nursing and is a viable alternative for those who no longer can or want to work at the bedside. Plus, it gives you the opportunity to work a "normal" schedule of Mon - Fri, 8 - 5 pm, no weekends or holidays.