Nurses in this field coordinate care for patients receiving long-term therapy, providing for optimal timing in all aspects of treatment. For cancer patients, for example, they coordinate primary care visits, surgery, radiation, and chemotherapy. A Nurse Case Manager usually specializes in one specific area such as AIDS, geriatrics, or children.
Case Management
The goals of case management are to facilitate:
1. timely discharges
2. prompt, efficient use of resources
3. achievement of expected outcomes
4. collaborative practice
5. coordination of care across the continuum
6. performance improvement activities which lead to optimal patient outcomes
Service-based registered nurses monitor the utilization and quality of health-care services and intervene as necessary.
In several different environments, a case manager can be described as different things for different services. A social worker can be defined as a case manager, especially in a mental health setting. They are the case managers accountable for their clients continuing to access the systems available in their area.
A nurse case manager can be defined in three different ways. In some hospitals or hospital systems, there are three integral parts that create a case manager. Some are independent, a combination of one, or all of the below criteria.
Utilization Review Manager: Either by the hospital or by the insurance company that runs the hospital, these ‘case managers’ review charts for the use of interdependent hospital systems, timeliness of service as well as safe and appropriate ‘utilization’ of services, URM is the department that’s accountable for other private insurance’s certifying and approving acute and non-acute hospital stays, with the information provided by the URM nurse. The URM nurse uses a standardized schematic of diagnosis, procedural transactions, possible complications, and standardized timelines in which to account for the changing diagnosis.
The URM nurse works closely with a UR/QM physician for monitoring quality services to the patient. If after review of the patient’s stay and utilization of services, a patient no longer needs the stay in an acute care setting, the URM nurse may request that the patient have outpatient or other services provided for the patient to the attending. If the attending physician is not in agreement, the URM nurse may contact this UR/QM physician liaison. This is usually one of the many attending physicians already at that current hospital; or in some cases, the physician that is the director of that HMO/PPO. This physician will review the chart, current prognosis and discharge plan. If the Physician Liaison agrees with the URM nurse, this physician will essentially go over the attending physician’s head to discharge the patient to the next lower level of care. It usually occurs as a conversation between physicians, so that the attending physician can still make integral decisions on his patient’s behalf.
To be an effective URM nurse, at least 3 years of acute hospital experience is recommended. The RN needs experience with standard procedures, and time lines of outcomes as well as the possible expected complications.
Quality Management: In most hospitals this portion is usually independent of Case Management. But, the smaller the hospital, the smaller the budget for such things. QM or QRM nurse, much like a URM nurse is accountable for the overall quality of care being delivered. This nurse may also be found in the Risk Management office working with the hospitals risk management team, ‘putting out’ any legal fires that may occur during a patient’s hospital stay. Again, this nurse will also work with the QM physician and attorney liaison.
Discharge Planner: A discharge planner is a nurse that coordinates all the facets of a patient’s admission/discharge. This nurse evaluates all high-risk patients with high-risk diagnosis, i.e. stroke, MI, complicated pneumonia. It is the discharge planner that plays investigative reporter, making available all the social and financial resources that the high-risk patient has. This is done for the purpose of a safe and viable discharge plan set originally by the DRG’s. The nurse uses his/her experience and assessment skills reviewing the patient’s current course, past medical history and of course, what family/friend support there is outside the hospital. The discharge planner is also familiar with Medicare/medicaid guidelines,and fee for service items that would qualify a patient for another level of care. Example: SNF stay, sub acute stay or outpatient, home care referrals. The discharge planner, depending on the hospital can cover up to 40 patients or more. The ideal system would be no more than 20.
Given the current standard of pay and accountability the discharge-planning nurse has, not many nurses are interested in this field. Its schedule, Monday through Friday, 9-5 is the only really attractive piece for most RN’s.
Case Management Nursing Career Profile
If you’re interested in a new direction for your nursing career and are interested in ensuring that patients and their families receive quality, cost-effective health care, then you might want to look into Case Management Nursing. Case Management Nursing focuses mainly on planning and managing all aspects of patient care and services for their assigned cases.
Case Management Nursing duties include assessing and monitoring patients, determining eligibility for treatments, making use of clinical pathways in order to determine whether the plan of care being provided meets the patient’s needs, and arranging for additional services as needed in order to help patients achieve desired outcomes. A Case Management Nurse conducts research, analyzes data, and coordinates patient care with all members of the patient’s health care team providing each patient with individual planning and planning in order to ensure optimum outcome while also seeking to ensure care and services provided are appropriate to patient needs and are cost effective.
Case management nurses help patients and their families by making sure that procedures approved by their organizations hopefully lead to quantifiable results instead of unnecessary procedures without possible merit.
Case Management Nurses Help Achieve Positive Patient Outcomes
The main goals of a case management nurse is to make sure that the patient receives quality and appropriate care as well as the most cost effective services. This usually requires working directly with patients and/or their families, developing a professional relationship with them in order to perform assessments on the patient, as well as analysis of data. Once an assessment has been completed and all proper data has been collected, the case management nurse works in close collaboration with the patient’s physician and all members of the health care team in order to coordinate and manage all aspects of that patient’s care and services including arranging referrals as needed.
One of the ways you might expect to use your skills as a case management nurse is if a patient that is covered under a certain type of health insurance policy is asking for a certain surgical procedure that can improve their ailment. If it is a procedure that is not common or is very expensive, a case management nurse may contact the patient and the doctor and find out if there are benefits to performing this surgical procedure for the patient. This requires the case management nurse to collect information about the patient, do research on the surgical procedure and analyze other data relating to the procedure so that this information can be prepared and sent to a person qualified to make a decision on whether an insurance company or other agency will pay for the procedure.
Work Environment & Salary for Case Management Nurses
Case Management Nurses have the ability to practice as independent consultants or to work for hospitals, physicians, specialists, rehabilitation agencies, insurance companies, workman’s comp providers, home health agencies, long term care facilities, private corporations, and for government agencies. Nurse Case Managers provide their services in the hospital setting, in outpatient settings, and also in the community.
One of the reasons to look into earning your certificate as RN Case Manager is its rather generous salary. The top tier of nursing case managers make well over $75,000 per year and those working for government agencies such as worker’s compensation providers typically earn over $55,000 per year. Compensation usually varies by location, job skills and experience as well as the types of cases you handle. For instance, workers comp and managed care cases may be on the lower end of the pay scale, while employment at a large name corporate insurance office will pay much higher.
It’s Never Too Late to Become a Case Management Nurse
If you are thinking about a career in case management nursing, one of the best ways to achieve this goal is by earning your Case Management Nursing certificate online. Kaplan University offers a totally self paced 100% online Case Management Nursing Certificate program that can be completed within twelve months at your convenience, providing you the ability keep your present job and income while becoming certified. There are many other online sources to check out when you are looking to learn about Case Management.
Most Case Management Certificates requires students to take these classes:
- Introduction to Case Management
- Case Management Process
- Case Management Tools
- Quality Measures
- Disease and Disability Management
- Case Management for Pediatric and Geriatric Populations
- Legal and Ethical Issues in Case Management
- Designing Case Management Models
If you are looking for an extremely challenging and fulfilling career helping patients and their families get the best possible care as well as making sure the medical procedures involved are appropriate as well as cost effective definitely look into the career of case management nursing.
RNs Enter Case Management Field Through Post-Graduate Degree Program Work
Patient Advocacy and Carefully Monitored Care Plans
Case management RNs work in a patient-centric specialty of nursing. Patients with extensive health care requirements, including tests, treatment, procedures, and diagnostic services, are expected to be unable to always direct their own care or rely on others to keep their care well-planned. Given the increasing specialization of medicine, fewer patients and family advocates are capable of charting a clear course of treatment, differentiating between necessary and esoteric care, and considering costs and insurance coverage issues. In some cases simply trying to translate physicians’ diagnoses and the medical jargon of a wide array of disparate specialists can be a daunting, financially costly, and ineffective task. This is where a nurse case manager comes into play.
Professional Patient Advocate
The first tenet of nursing is to work as a patient advocate. There may be no more precise application of this than in nurse case management. RNs use skills of assessment, care plan design and patient education to develop a carefully designed timeline of patient care. Case managers work closely with patients and associated family advocates, consult with other patient physicians and specialists, and monitor ongoing patient medical services. As care progresses, nursing professionals review medical progress, assure consistency in the services, and support the patient that may be frustrated and anxious going through lengthy medical care.
Types of Patient Populations
Patient populations of concern for nurse case managers include:
* Elderly and Medicare patients.
* Children with complex medical histories.
* Patients with extensive traumatic injuries requiring long-term follow-up.
* Cancer patients.
* Patients with limited outside family support.
* Psychiatric patients.
* Any medical patient that may be involved in long-term medical processes, or that presents an unusually diverse array of tests and procedures.
Nurse case managers may work in hospitals, outpatient clinics, long-term care facilities, and in community and public health settings.
Degrees and Qualifications
For the most part nurse case managers with Masters in Nursing degrees are preferred for jobs. But RNs with four-year BSN degrees may be experienced enough to work as case managers. Qualifications for most job positions include RN licensure, work experience in critical care, and preferably work with specific patient populations such as geriatric patients and Medicare patients. Nurses experienced with HMOs and other types of medical insurance are also preferred.
Credentials
Nursing industry credentials may be varied and not required by all employers. However, professional certification credentials indicate dedication to one’s career and often provide an additional facet to an experienced nurse’s resume.
* The American Academy of Case Management offers the Fellow in American Academy of Case Management (FAACM) certification. This includes a 60-hour course, exam, and/or validation of work experience in a case management setting.
* American Case Management Association supports the profession of hospital case managers. The organization promotes and encourages hospital-based nursing professionals to earn the Accredited Case Manager (ACM) certification. Candidates must be RN licensed and have at least two years work experience as a clinical nurse in a hospital setting.
* The Commission for Case Management Certification is one of the more popular and nationally recognized certifying bodies in case management. Certified Case Manager (CCM) certification is targeted to a wide range of case management health professionals, not just nurses. Nurse candidates are required to have a degree and licensure as an RN.
Medical specialization continues to drive the need for professionals like Case Management Nurses. Patient advocacy takes precedence in case management and nurses are expected to have more job growth potential than almost any other industry.
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