case managers – JRM Nurse Consultants

February 02 2017

Rapid Changing Healthcare System

In our rapid changing healthcare system, it is very important to be able to have information at the tip of our fingers so that we can best help our patients. How great it is to have the patient’s medical records available after entering their information in the system when the patient asks a question. My favorite thing about having the patient’s information at your fingertips, is when a patient calls me, to help me remember them I always jot down some personal information about them; for example, one patient loved to watch her Spanish soap operas, another had a pet bird named Sam. Knowing these trivial things helps me build a relationship telephonically with the patient, this allows me to ask about it so that when it comes time to discussing their healthcare and goals, I have established a trust to build a stronger effective care plan.

Critical thinking needs to be incorporated in to the informatics process. Through critical thinking and informatics, we are encouraged to consider our own needs, have positive feedback and think logically to assist us to make good decisions that are based on evidence rather than on emotional feelings (Rubenfeld & Schaeffer, 2014).

References

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

January 01 2017

Best Practices for Informatics

The informatics that is available to nurses is amazing. Although there is always going to be something that someone thinks of that will improve the quality and speed of how we do our jobs, we as nurses have to be willing to have intellectual integrity that moves us beyond our own needs (Rubenfeld & Schaeffer, 2014). I used to work remotely from home as a manager for field case managers. Our case managers would go out in the field and see the members on our health plan. They carried a laptop so that they could document anywhere and pull up their member’s information. Of course the security to get into the laptop was only via an ever-changing token so that they could access it. With protected health information, the nurses had to be extremely aware of technology.

Years ago, many nurses had to document on paper when they would visit a patient in their home and they carried a paper chart in their car. Informatics has improved in leaps and bounds.

When the case manager is at the member’s home, they are able to do their assessments right in the member’s home and share the outcome from the assessments with the member. Meetings were held via WebEx when we had them because everyone worked from home. This made training on a new process easier giving everyone the ability to receive new information at the same time.

We also had a patient interface after the member was enrolled in our program. The member would get in the patient status screen and would be able to add goals to their plan of care that they wanted to work on. When the member filled this out, the nurse on the file would receive an alert that someone updated their file.

Close-up of happy female doctor talking with senior patient at clinic.

I see many opportunities for transforming knowledge from the use of informatics. For instance if we were able to send doctors an email right from the member’s file, and get the reply from them instantly, it would cut back on the time and phone calls to doctors to get certain forms filled out for the teams throughout. Some nurses that did not grow up with computers may have a challenge adapting, but with some education that can be done right from WebEx, they can learn. Computers and their programs are not going anywhere; they are the wave of the future.

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

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

February 02 2015

Role of Professional Nurse

The role of the professional nurse when implementing a change is to identify that there is a need for a change. (Rubenfeld & Scheffer, 2014, p. 321) 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, p. 324)

Some companies are very involved with AHCA (Agency for Healthcare Administration) because they hold a state contract. Evidenced based nursing is in a sense required as far as the patient care when case managers are managing a case. However on the same note, although case managers are not performing hands on care, they are required to know about all their patients’ diagnoses and treatments. These companies have social workers and nurses alike seeing the same types of patients. The issue that comes up with nurses and social workers seeing the same types of patients is when the social worker is not able to use his/her critical thinking skills in their area of expertise. The social workers are required to case manage a patient having medical issues that can possibly be on a ventilator or have more complex medical problems. Some companies, utilize social workers to assist patients with the community resources that they are all too familiar with. While other companies, say ACHA is not paying the company to rethink how cases are managed and by whom because it is not hands on care, it is case management.

These days nurses can work in many diversified places, even in corporations such as insurance companies. The problem for some places that employ nurses in a corporate role, is that there is very little nursing involved in their job role. Sometimes it is primarily reports, meetings to talk about reports and how to fix these reports. It is an ideal job for someone that has an interest in perfection of numbers and statistics. Most nurses are not geared this way, they are geared to use their critical thinking skills. As a nurse seeing that every other day there is a new change that is being implemented, will often make the nurse question why there is a change, but only too often to be told that the change is immediate and mandatory.

Nurses who are managers and supervise case managers have to explain new changes to them. For the case managers, these changes are difficult because the staff is in the field. They may receive an email about something needed to be changed as soon as possible, however they may have just returned home at 4:30 or 5pm in the afternoon looking forward to the end of their day. They check their emails and find deadlines on multiple items due. These changes affect the staff because they have to stay late after hours to get the work completed timely. This kind of change can cause many good nurses and social workers to resign.

As nurses or leaders we can 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.

Change is inevitable and we all have to change, but the way we implement those changes can be the success of the process being changed.

Author John Maxwell states, ” If you want to change your life, you must first change the way you think..”

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

(Rubenfeld & Scheffer, 2014, Chapter 11)

Written By Rosie Moore, RN, BSN, LNC

February 02 2015

How Do You Use Your Critical Thinking Skills

Professionals use critical thinking and problem solving strategies daily in their work environment. Take for instance a health plan managing their member’s health, consisting of a staff of social workers, RN’s and LPN’s they will manage all kinds of medical conditions. The case manager is expected to apply critical thinking skills to each case and prioritize what that individual member needs. As an organization in healthcare they are to effectively encourage behavior change in members towards a healthier life that will avoid gaps in their healthcare treatment. The case manages are also required to achieve the business goals of the company by submitting state required forms timely to AHCA (Agency for Healthcare Administration). With each member that the case manager interacts with, they will be advising them of what care is covered under their plan, how they can best utilize the health plan to empower them to live a healthier lifestyle by complying with such things as attending their doctor’s appointments, taking their medications and reporting changes in their health, socioeconomic status or if their living arrangements are no longer safe for them.

Every organization can improve the critical thinking of their staff, but the reality is that it is the staff member that needs to utilize their critical thinking skills to make that change. One thing I learned is that “To provide quality care in this environment, nurses need to develop critical thinking (CT) skills that will provide them with expertise in flexible, individualized, situation-specific problem-solving.” (Brunt, 2005, p.60) When I think of how some case managers use critical thinking skills, I become concerned. For example, I will share a story of a time that a social worker went out on a field visit with a nurse to a nursing home. The social worker had already informed the accompanying nurse that the member was non responsive and she will either sleep through the visit or have a blank stare. One of the first things the nurse noticed when she came in the room was that she had slipped in her hospital bed to the side. It is noted that the insurance company case managers do not do hands on care, so the social worker will have to let the nursing home staff know to readjust her.

Second the nurse accompanying the social worker noticed that she had a big bump on her forehead, she questioned the case manager but she did not know where that came from. The nurse quickly used her critical thinking skills to scan the situation and see that the member probably had slipped. During the nurse’s visit, she noticed that the member had too many pillows behind her back; she was a light weight and was slipping to the side about ready anytime to hit her head on the same spot with side rail. This led the nurse to believe that this was not the first time this had happened to this member. The nurse and social worker let the staff know on the way out of the member’s room.

However, in thinking about the list of 17 Dimensions of Critical Thinking in Nursing, a few critical thinking skills stand out in my mind for this situation that I was hearing about. When analyzing a situation, if the case manager is not a nurse who is used to doing head to toe assessments, would she have known that bump on her head was the result of the member falling sideways and hitting it on the side rail in the very same position that she was found in? If the social worker did not seek information from the nursing staff to ask about the bump on the member’s forehead and was only concerned for what is in the member’s chart, then she would not have the correct information to formulate a plan of care that will benefit that member. If the social worker could predict what would happen if the member continued sleeping sideways on the bed propped by pillows, then she would be using her critical thinking skills to avoid an incident. Transforming knowledge can only happen when you have a working knowledge on any subject. If you have not been taught how to do a physical assessment on someone, then you are not able to transfer what you were taught in a book to a real life situation that will require critical skills thinking to resolve a problem. (Rubenfeld & Scheffer, 2005, p. 2)

Rubenfeld, M. G., & Scheffer, B. K. (2005). Critical Thinking TACTICS for Nurses: Achieving the IOM Competencies (3rd ed.). [Vital Source BookShelf]. Retrieved from http://online.vitalsource.com/books/9781284059571

Written by Rosie Moore, RN, BSN, LNC

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

Tag Archives: case managers

Rapid Changing Healthcare System

Best Practices for Informatics

Multiple Factors Can Interfere With Teamwork