I am an RN with 26 years of continuous nursing experience. At this stage in my life, I have become very interested in case management (CM) and would like to get certified. However, I need to first find out how to proceed. Would you be so kind as to give me some tips as to the best way to go about this? Also, I am looking for employment in CM, as I am getting a sense that this is necessary for certification. A great many positions require one to be certified before they will consider you for employment.
A
I get e-mails such as this several times a year. The field of CM is so complex that my first question to these individuals generally is, “What kind of CM are you interested in pursuing?” Often they have no idea and don't even realize that the field is so broad. Some types of CM are episodic in nature and deal only with a short-term problem the patient is having (durable medical equipment, or DME, CM), whereas health or workers' compensation insurance CM may require years of management.
I usually start by asking some basic and simple questions:
•Do you prefer to work directly (face to face) on a daily basis with patients and their families?
•How would you feel about traveling several hours to attend doctors' appointments with your patients?
•Would you be comfortable working at a desk and having most of your contact with patients and providers via telephone?
•Are you comfortable working with irate family members who can't agree on a discharge plan?
•How would you feel about telling a patient who wants to go to a particular hospital, rehab center, or skilled nursing facility that it is not in her network?
•Do you prefer working closely with your cohorts, seeing them daily, or do you like to be independent and out on your own?
•Do you like to be busy and accountable for your time, or do you prefer a more laid-back and spontaneous workplace?
These are all questions that might help someone who is interested in CM pinpoint what arena they might want to pursue. Of course joining CMSA, OHN, and local Rehabilitation Insurance Nurses Group (RING) are great ways to network and may help you decide if the field is right for you. Many of these groups have annual meetings that provide information on available positions in their area. Although certification is an important asset in CM, knowing what area of CM you might enjoy should come first.
I decided to go to some of my CM cohorts from different fields and ask them what backgrounds they look for when hiring new case managers. Here are their replies.
Group health insurance case management
Sue Kozieja, manager of clinical support services at Bowers and Associates, endorses the need for a broad clinical background that focuses on discharge planning. “Someone coming from a narrowly defined background such as obstetrics or inpatient med/surg may not understand the dilemmas that case managers face when they are trying to transition a patient down the continuum. I would want to know that any case managers I hire know how to get services for a fragile patient in the home setting.”
A home health care background would reassure Sue that the CM applicant understood the various levels of care and how one needs to work within the confines of Medicare, Medicaid, and insurance reimbursement guidelines.
Inpatient rehabilitation case management
Georgeanna Blackburn, lead case manager for three specialty hospitals in Phoenix, sums it up this way: “The insurance CM market was the best preparation I could have gotten for transition into the inpatient market. With my understanding of insurance benefits—or lack thereof—I am able to determine possible barriers to discharge prior to admission. This also gave me the utilization review (UR) piece to know what the UR nurse wants in a regular update.
“Although being certified is a plus, one should plan on working as a case manager at some level prior to attempting certification. Inpatient CM varies between facilities. A case manager at one hospital might do only discharge planning, whereas at other facilities, the case manager might be the social worker, discharge planner, liaison between family and physicians, etc. Using the term case manager is like using a diagnosis of deconditioned—what does it mean?”
“Case management in the inpatient setting also varies between the short-term acute care hospital and the long-term acute care setting. The focus is different at each level of care. Case management in the inpatient setting can be very rewarding, with very positive outcomes, but it can also be very trying, with difficult families, unrealistic goals, unsafe discharge plans, etc.
“My recommendation to the ‘newbie' would be to start CM training on the insurance side of the fence and then go for certification when ready. When and if you want to jump the fence to inpatient care, the journey will be much smoother with a good insurance understanding and background.”
Inpatient pediatric case management
Ann Strakulski, case manager at Milwaukee's Children's Hospital, believes that a good background in insurance CM and home health is important factor in being able to anticipate the needs of the discharging patient. She suggests that these backgrounds afford you the knowledge of what support systems are out there. The knowledge encourages you to see the big picture, what might help the patient and family.
Ann believes she would not have been as well-rounded if she had only an inpatient background, because being an inpatient case manager is really dealing with discharge planning, which often includes home care needs (to facilitate a timely discharge).
An insurance background helps in knowing how to access providers, checking which ones are in network for the patient, and getting information regarding benefits available. The positive side of inpatient CM is the active, face-to-face contact with patients and families and developing relationships over time with the “frequent fliers,” such as oncology and transplant patients. Ann says she loves her position as home care coordinator because it combines her background in pediatrics, home care, and CM.
Workers' compensation case management
Liz Thompson, director of CM for Encore Unlimited, suggests that because disabled workers often have to deal with limited mobility, change of lifestyle, and chronic pain, she prefers that her new hires have a background in chronic pain, physical medicine, orthopedics, psychiatry, or home health care. She recommends that individuals interested in CM Google their state's CM companies to identify who is who. She also suggests preparing a résumé that highlights any previous abilities or experience in coordinating services, dealing both on the phone and in person with all kinds of people and mentioning any special experience or ability in handling conflict and developing action plans.
Informational interviews at prominent CM firms also should be part of a new case manager's research portfolio. Some firms will even consider allowing a potential new hire to “shadow” an experienced case manager for a day or two to promote hiring only those individuals who are certain that CM is truly the field in which they are interested.
Home health case management
Judith Hempke, director of home health and hospice for Horizon Health Care Services, believes that home health care is one area that welcomes any applicants with a broad clinical background and a willingness to learn. If the agency is large enough and has extensive training and orientation programs, they may be willing to train a nurse who has only a narrow inpatient background. She suggests that any nurses who desire autonomy but are team players and thrive in an ever changing environment would do well in home health CM. The home health case manager must have an eye for detail, because the paperwork necessary to collect reimbursement must be complete and up-to-date at all times.
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