case manager – JRM Nurse Consultants

October 10 2018

Strategies on Cultural Competence

In my own nursing career as a supervisor for field case managers, I have encountered patients and staff that come from diverse cultures. Every two weeks, our entire region would participate in Grand Rounds and during those rounds, our medical director reviewed four cases that had been submitted prior to the meeting in order to evaluate them for a better plan of care to help the patient. My team consisted of a mixture of different cultures. I had some wonderful nurses from different Caribbean Islands, some of them had a very strong accent, but that did not stop them from providing good care.

During our grand rounds, the medical director selected two of my case managers to present their case. The case was presented in our own team meeting and as a team, we thought it would be a great case to present. The one case manager we will call her Ms. R. presented a case about a member that had too many cats in the home and she was having difficulty staffing the case with home health aides because no one wanted to go in the home with so many cats. The medical director gave his evaluation of the case and the case was closed with the new information for the nurse case manager to implement.

During a manager meeting with about six other managers, the topic of case presentations came up and how each team needed to submit two cases per week, even if they were not selected for grand rounds. A manager from England, who spoke with an English accent, stated that my team presented a lot of cases all the time. I confirmed and stated that our strategy was that in our team meeting as an exercise we would bring two every week so that everyone had a chance to comment and it helped the presenting nurse in case her member was selected for grand rounds. The English nurse manager asked me how I even understood Ms. R. and a few other staff from the islands that I had. I politely let her know that I did have a diverse team and every one of them was a great nurse or social worker and did their jobs quite well. As for understanding them, I listen to what they were saying intently and I did not multitask when they were speaking so that I could capture every word they said. Her response was “I am glad that they are on your team (Clark et al., 2011).”

A week later, I resigned from that position and unfortunately for my staff four of the team went to this one manager and the other nine went to someone else. But of the four there was one from Haiti, one from Grenada, one from Puerto Rico and the other one was African American. I heard from all four about the poor treatment they were receiving from this manager. I, of course, could only listen, since I was no longer working there, but this is a perfect example of how not all nurses follow the code of respect of others cultures.

With patients, it is the same thing, as nurses, we are not always going to understand what someone is saying whether it be a language barrier, dysphagia from a stroke, or dementia, but as nurses, we need to be able to read the body language. We need to fine-tune our ears to try and understand what the person is saying. Living in Florida I am exposed to many cultures. I myself am of Hispanic descent and although born in the states, I understand the diverse cultures that there are here.

In integrating health teachings, many materials are available in Spanish and Creole, However for the ones that are not, the use of translation companies are available through hospitals or managed care companies to help with the teaching that we are offering the patients.

References

Clark, L., Calvillo, E., De La Cruz, F., Fongwa, M., Kools, S., Lowe, J., & Mastel-Smith, B. (2011, May-June). Cultural Competencies for Graduate Nursing Education. Journal of Professional Nursing, 27(3), 133-139.

February 02 2017

Leadership Styles and Organizational Changes

The role of the professional nurse when implementing a change is to identify that there is a need for a change (Rubenfeld & Scheffer, 2014). Once the need for a change is identified by the nurse, the next step is to implement a change in behaviors efficiently and with quality. When identifying the area specifically that needs the change, nurses need to be deliberate in stating the purpose for the change. When speaking to the target group about making the change, it is important to keep their attention span with non-lecturing phrases. As nurses we are not always in our comfort zone to explain why changes need to be implemented. We should be prepared to explain why this change is needed and what improvements these changes will make.

Generally, people will always be resistant to change. But as professional nurses, our focus is to build trust and credibility. The goal is to acknowledge that the change is coming and that you empathize with the feelings of the upcoming change (Rubenfeld & Scheffer, 2014).

Where I used to work, they were very involved with ACHA (Agency for Healthcare Administration), because we held a state contract. Evidenced based nursing was in a sense required as far as the patient care when our case managers were managing a case. However on the same note, although our case managers were not performing hands on care, they were required to know about all their diagnoses and treatments. We had social workers and nurses alike seeing the same types of members. The issue with nurses and social workers seeing the same types of patients is that the social worker is not able to use his/her critical thinking skills in their area of expertise. They were required to assist members who had complex medical issues for instance, on a ventilator or more complex medical problems. A suggestion was made when I arrived at my work place to utilize the social workers in conjunction to the nurses to manage the social aspects of the patients, however the decision was denied. It was noted that ACHA is not paying the company to rethink how cases were managed and by whom because it was not hands on care, it was case management.

There was very little nursing involved in my job role, it was primarily reports and meetings to talk about reports and how to fix these reports. It was an ideal job for someone that had an interest in perfection of numbers and statistics. Every other day, there was a new change that was being implemented. We often times questioned why there was a change, but what we were told was that the change was immediate and mandatory. For the staff case managers, these changes were difficult because the staff was in the field. They may receive an email about something that needed to be changed as soon as possible, however they may have just returned home at 5pm in the afternoon looking forward to the end of their day and they find emails with deadlines on multiple items due. These changes affect the staff because they have to work late hours to get the work completed timely. This kind of change caused many good nurses and social workers to resign.

As nurses or leaders we tend to fall in to the routine of lecturing due to the pressures that we are under. However two of the six dimensions of dealing with complex dynamic changes are creativity and intuition. As a leader we should not just teach our group something, we should implement a way to bring creativity in to the change and use intuition to know how to speak to your group. The best way to implement a change is to get the group to commit to doing the new change and develop a smart goal with them that will allow them to measure their own goals.

The leadership theory that most resembles mine is the coaching leadership style. The coaching leadership style allows me to work closely with the staff at different levels and empower them to meet their goals and gain confidence of their strengths so that they can focus on them as they work on their weaknesses. In my previous job, the leadership style could have been called a dictatorship, however for the purpose of the discussion here it will be stated as coercive.

My manager’s favorite phrase was, “I gave a directive and everyone needs to follow it, any questions (1 second wait) no, good. It’s due by close of business.” If questioned on how to juggle that with all the meetings and other directives, the reply was always as a manager makes it happen. My manager always reminded me that she did not take lunch, breaks and basically had “no life” outside of work and she expected those under her to be like her. She was not a woman who read books as a matter of fact, she indicated that books were a waste of time, for fun she read the ACHA contract that was 350 plus pages because reading any other book was pointless (Barr & Dowding, 2012).

References

Barr, J., & Dowding, L. (2012). What makes a leader? In Leadership in healthcare (2nd ed., pp. 13-31). [Vital Source Bookshelf]. Retrieved from https://campus.capella.edu/web/library/home

Rubenfeld, M. G., & Scheffer, B. (2014). Critical thinking and patient-centered care. In Critical thinking tactics for nurses: achieving the IOM competencies (3rd ed., pp. 155-180). [Vital Source Bookshelf]. Retrieved from https://campus.capella.edu/web/library/home

January 01 2017

The Future of Nursing Your Workplace

I was recently speaking to a nurse about her current work place and some of the changes that she sees coming. She was concerned for the safety of her patients with many changes that will take place putting more work on the nurses and not for any greater pay or benefit. I explained to this nurse about a previous place that I was employed at and how I had to break away because I was not using my full potential as a nurse.

In my previous work environment, my position was a manager of long-term care case managers. The Institute of Medicine(IOM) report was not shaping our scope of practice at my previous location. The organization was very top-heavy and there did not seem to be enough people to do the jobs that directly affects the population that we serviced, which was the Medicaid and Medicare population. The training that was provided to the staff was more on how to complete reports and paperwork that was required by the state of Florida in order to be in compliance with AHCA.

The issue with this was that the members were not being followed up with properly. Nurses and social workers were going through the motions of case managing their files, with basic monthly telephonic questions asking a member living in the home how things were going, have they received their supplies was there anything new that they should be aware of. A monthly contact should involve so much more, but yet it didn’t because the case managers did not have enough time to fulfill the job in eight hours and they would work for 12-15 hours daily some of them, to get documentation done in order to avoid a reprimand by upper management.

In the IOM report there are six aims that healthcare providers should follow and one of them is patient centered healthcare (Rubenfeld & Schaeffer, 2014, p. 82). The goal of the health plan was to have patient centered care and have policies in place for it. The case managers did everything in their power to obtain services for the members and get them started as soon as possible and formulate a care plan with goals. The challenge that they were running in to was that the case managers were out in the field 4-5 days per week, they didn’t have time to complete the documentation of their assessments while they were in the member’s home, therefore creating more after hours documentation for the case managers, dissatisfaction with the job and more report concerns rather than focusing the time speaking with the member to really understand what the member’s needs are.

The nurses and social workers were not able to apply quality improvement plans because there was little collaboration as an interdisciplinary team. Nurses and social workers both did the same assessments and did not have the ability to collaborate on a case as if they were both co-managing the case.

The nurse I was speaking to was amazed that this happened in the work place that I used to work in. I explained to this nurse that the IOM report would not shape my career as a doctorate of nurse practice (DNP) at my former job because the region that I was in did not support critical thinking or any type of evidenced based nursing. The rigid structure would remain and no changes unless implemented or suggested by upper management would be considered in our department.

Now as a DNP on the outside of this organization, the ultimate goal is to consult with nurses, doctors. therapists, nutritionists and specialist to get the right people involved in carin for a patient whether at home or in a facility. It is good to have a future goal with a plan in place to reach that goal.

Two Businesswomen Meeting Around Table In Modern Office — References

Rubenfeld, M. G., & Schaeffer, B. (2014). Critical Thinking Tactics for Nursing Achieving the IOM Competencies (3rd ed.). [P2BS-11]. http://dx.doi.org/

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April 04 2015

Multiple Factors Can Interfere With Teamwork

In every organization there are communication barriers, but overcoming them is part of being professional and respectful of others’ opinion. In some organizations the leadership structure has a medical director, senior health service director, a health service director, a manager and the case manager. The case manager manages the file, develops the plan of care with the assistance of the member or the family. The nurse is responsible to ensure that the member is attending their doctor’s appointments, taking their medications and maintaining their insurance eligibility monthly. This should be done by the social worker however in some organizations, the social workers manage the same types of patients that the nurses manage.

There are other professionals on the team that help maintain the members with their eligibility for their Medicaid insurance. Part of the team is the operations team. This is where things in an organization get blurred due to communication gaps, lack of resources, support and professionalism. The team in operations are not nurses. The operations team will email the nurse and copy the manager to let them know that the member is going to lose eligibility if they do not send in their paperwork timely to the state. When the nurse receives this email, the nurse is to drop all that they are doing to attend to the member’s eligibility. This will involve contacting the state to see what is happening with their eligibility. This is something operations can handle but they state their function is just to advise the case managers of the discrepancy.

Another barrier that is seen in management of cases is the inability to show respect to other team members and allow a learning environment. One agency case manager stated that every two weeks the team of case managers reviews case files on a conference call with the medical director. These cases are reviewed in their team meetings weekly before submitting to the medical director and as a team they discuss what has been done and make suggestions. The cases are emailed to the medical director and his assistant selects the cases. Recently, a case manager stated that two cases were selected for review from her team. The case managers present them to about one hundred and eighty people or more on the call from directors to managers and case managers. As the doctor asks his questions and makes his recommendations, the case manager indicated that her director, who is her manager’s superior, made a statement on both cases stating to the team that their manager should have known this and taken a different approach before sending this to review. The case manager did not know what to say, but this was stated over and over about five or six times throughout the presentation of both cases. At the end, what was stated by that director was if your manager does not know what to do, then call her. This is a prime example of a barrier in trying to be in a learning environment that will help the case manager grow and benefit the patient. (Rubenfeld & Schaeffer, 2014)

Collaboration can only exist in a team when the leader uses critical thinking, an interdisciplinary team approach and collaborate on cases together. But in the big picture of corporate America under some managers this is not acceptable, it is more along the lines of a multidisciplinary team. In this type of team, you only have individual thinking in the group, meaning their way and no other opinions. The focus will be on tasks and check off systems regardless if it is feasible to do. (Rubenfeld & Schaeffer, 2014)

In conclusion, nurses do have the ability to be leaders, educators and changers of a system, if assertive enough to make that change, but in order to do so a good team of interprofessional people are needed. Because at the end of the day, the patient is who counts and why changes are necessary.

References

Rubenfeld, M. G., & Scheffer, B. (2014). Critical Thinking Tactics for Nursing Achieving the IOM Competencies (3rd ed.). [P2BS-11]. Retrieved from http://online.vitalsource.com/books/9781284059571

Written by Rosie Moore, RN, BSN, LNC

April 04 2015

The Nurse Leader of a Healthcare Team

A nurse can play three different roles as part of an interprofessional team. The three roles consist of a nurse, nurse leader and nurse educator. The interprofessionalism team consists of other healthcare workers as well, not just nurses. (Sommerfeldt, 2013) However as nurses the roles can be at different levels depending on the patient’s condition. In speaking with a complex case manager working for a managed care company, the team consisted of registered nurses, social workers (masters prepared) behavioral health specialists, community health workers and nutritionists. The nurse case manager managed the patient, however if there was an issue with the patient in the home setting that required community resources, the community health worker would be consulted to assist in those needs. If the member had psychological issue or other financial issues that required the need of a social worker or behavioral health specialist, this referral would be added as well. There was collaboration on the plan of care and all participated because they were all looking at the patient as a whole, not just as the part that each discipline took care of. If the member cannot pay his light bill or water bill due to financial difficulties, until they take care of those needs through resources, any teaching that the nurse does would be in vain. A person cannot focus on teaching for their health or anything else if their mind is on their current financial strain, not their medical condition. In this instance the nurse is playing the role of the nurse leader.

When a patient is in the hospital a nurse can also play the role of a nurse that is doing dressing changes, medication administration and other treatments. The nurse’s role in the interprofessional team that may consist of the doctor, physical therapist and dietician, would be more medically involved because maybe the patient is recuperating from heart surgery and requires a lot of care initially. The patient is on a special cardiac diet, which can also be explained by the treating nurse, however in this instance, the member is starting something new, so a consult from the dietician can help the patient understand the diet and the nurse can reinforce the teaching.

The nurse educator as part of the interdisciplinary team can be seen for example in a disease management setting. This type of setting also has multiple specialties that can follow the patient. In this instance the nurse educator is educating the member on how to empower themselves and learn about managing their chronic disease by learning about taking their medications, following a diet and exercise program, learning to check their blood sugar or blood pressure. The nurse educator measures the members learning based on return demonstration through development of a plan of care.

All three roles bring value to the scenario that they are in, because the nurse is the one that will be around the patient most of the time. In each role the nurses is responsible for all aspects of the patient’s care. Regardless of which role the nurse is playing, working on an interprofessional teams is a style of partnership that allows decision-making to be collaborative. (Sommerfeldt, 2013) It takes many people to work together in getting a patient discharged to his home.

References

Sommerfeldt, S. C. (2013, February 25 2013). Articulating Nursing in an Interpersonal World. Nurse Education in Practice, (13), 519. http://dx.doi.org/http://dx.doi.org/10.1016/j.nepr.2013.02.014

Written by Rosie Moore, RN, BSN , LNC

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Years of experience in Work Comp, Case Management, Disease Management, Utilization Review and Prior Authorization.

Tag Archives: case manager

Strategies on Cultural Competence

Leadership Styles and Organizational Changes

The Future of Nursing Your Workplace

Multiple Factors Can Interfere With Teamwork

The Nurse Leader of a Healthcare Team