DP to fundraising: Rural case managers do it all

One-person departments do the work of many

A case manager in a rural setting often is responsible for what it takes an entire case management department to do in a big city hospital.

In addition to managing the care while the patient is in the hospital, they do all the discharge planning, making arrangements for medications, home health, durable medical equipment, or any other post-discharge needs, working with the insurance companies to get them approved.

They track quality measures, such as delays in treatment, avoidable days, and outliers.

"It's almost like trying to be an expert in a lot of different regulatory arenas," adds Lyn Clark, RN, BSN, case management director at Lake Granbury Medical Center in Granbury, TX.

Rural case managers must be familiar with what treatments Medicaid, Medicare, and commercial insurance will allow and what they will pay for them and must collaborate with the business office on financial issues.

"When a case manager is the only person on staff doing case management, he or she has to be involved with the financial aspects of care and how it can affect the bottom line of the hospital," says Denise Caram, MS, CPUM, CPUR, director of support services for Integris Rural Health, a system of eight rural hospitals with headquarters in Oklahoma City, OK.

CMs wear many hats

At Integris Rural Health, the case managers are in charge of utilization management along with the medical director, they sit on the hospital's quality committee, and sometimes are on the medical executive committee.

They are involved with the hospital foundations, working on fundraising efforts to provide funds for indigent patients.

Out of eight hospitals in the Integris system, six of them have only one case manager.

In addition to her duties as case management director at Bass Baptist Hospital, a 183-bed facility in Enid, OK, Gloria Ross, MBA, RN, CPUM, also is director of case management at the health system's children's behavioral health center, the skilled nursing facility, and the long-term acute care hospital (LTAC). She supervises a total of six case managers at the three facilities.

As the only case manager at the LTAC, she has to negotiate per diem rates with the insurance companies.

Ross spearheaded a fund drive for indigent patients who can't afford medication and frequently speaks to civic organizations on behalf of the hospital's foundation.

She meets with her hospital case management staff for 20 minutes every day and goes over their plans for the day.

"Some days, I feel like I can't get it all done. I have a lot of my plate, but my case managers know that I expect business as usual if I'm not on the floor. They know I'm just a beep away," Ross says.

When Clark became case management director at Lake Granbury Medical Center, it wasn't unusual for case managers to be asked to get blood from the blood bank, give a patient his or her medication, or even go to a patient's home and feed her cats.

"I've had doctors ask me to find patients jobs or apartments or to take their dog home with me. That's not my job, but I will plug them into community resources, and I can find someone who can call the ASPCA to find out if they'll feed the animals. Part of the role we play is to take the worry away from the patient. The doctor has known Mrs. Jones for years and knows she's worried about her cats," she says.

In a rural setting, case managers are asked to do myriad jobs that can be done by people with lower skill levels because nobody understands exactly what case managers do. If a case manager agrees to give medications or run errands once, the expectation is there that they'll do it over and over, Clark points out.

"When I came here, the nursing staff was used to having some additional hands and using case managers for inappropriate roles. We had to pull back and redefine the role and educate everyone in the facility. It has required a real change in the hospital culture," she says.

Clark advises case managers in small hospitals to help educate the hospital administration about the role of case managers and how they can help improve patient care and the hospital's bottom line.

"If they don't understand case management, they don't understand the benefits that case managers provide. They don't know the hoops that case managers have to go through with Medicare, Medicaid, and commercial insurance," she points out.

Case managers in rural areas must work closely as a team with physicians and have support from the physicians and the hospital management.

Originally, Integris Rural Health's case management model included both RNs and social workers as case managers, but the model has evolved so that only RNs are case managers.

"We realized that physicians were more comfortable in talking about clinical issues with a clinical person. It was a challenge for social workers when they were handling discharge planning issues that required clinical knowledge," Caram says.

Since the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that hospitals have a social worker, Integris has a social worker on contract who it can pull in when necessary or, if there is a home health agency or hospice in the network in that city, it utilizes that facility's social worker.

The case managers in many of the rural facilities call on the area's ministerial alliance to provide counseling if the hospital doesn't have a chaplain.

"The case managers are dealing every day with patients and physicians. A social worker can't write an order for a physician or take orders over the telephone. With the challenges we have, it's more feasible to have RNs and use others to pick up the social work piece," Caram says.

In a small town, everyone recognizes the case manager, and they don't hesitate to ask questions about advance directives, nursing home placement, and other concerns, says Ann Jacobsen, case manager at Clinton Regional Hospital in Clinton, OK.

"I do a lot of grocery store care management. It's not unusual for someone to call me at home and ask for advice about a particular doctor or whether their parent should go to Oklahoma City for care. It's all part of the job," she says.