Education helps CMs learn to do their jobs better

Training modules help nurses adapt to new role

When Lyn Clark, RN, BSN, became case management director at Lake Granbury Medical Center in Granbury, TX, she found herself with a staff working with no direction and who had very little knowledge about the role of case management in the hospital setting.

That was 18 months ago. After she developed and implemented an intensive training program for case managers, Clark has received accolades about her case managers' performance from her hospital's corporate office and, best of all, she can take a vacation without anyone calling her with questions.

In the first year, after the program was redesigned, the case management department was able to demonstrate that it had tripled reimbursement by improving documentation.

"The first thing I did when I came in was to talk with the case managers to assess their skills and find out what they were doing on a daily basis, then make suggestions as to how to perform their role more effectively," she says.

The hospital has two case management FTEs, split into three positions. Two of them work four days a week. The other works two days. Between them, they provide coverage seven days a week. A full-time case manager covers the emergency department 40 hours a week.

It took Clark about three months to get her case managers on track to performing genuine case management duties instead of running errands for physicians or helping at the bedside.

She repeated the same message over and over — that the case managers were going to focus on case management duties and not other tasks to which they had previously been assigned.

"It took some of the hospital staff as long as nine months to understand that some of the things the case managers were doing were not appropriate. I had to take a lot of heat and re-educate the nurses, the physicians, and the rest of the hospital staff about the role of case management," Clark says.

"In the beginning, I talked to the case managers about their role as nurses and how critical nursing skills play into case management," she says.

For instance, Clark suggested that the case managers evaluate whether the physicians were ordering what they expected to see when they worked on the floor. She found that case managers needed to change the way they worked with patients.

For instance, if there is a patient on a ventilator who is not likely to be discharged soon, the case managers need to concentrate on a patient who may be discharged the next day.

"With a ventilator patient, there's no point in picking the medical record apart because they aren't moving any time soon," Clark explains.

She covered basic information, such as which insurance company wants clinicals every other day and where the information should be sent.

"I went over Medicaid, assessing what the case managers know about Medicaid, such as the income level families must have to qualify," Clark says.

Clark keeps three-ring binders filled with pertinent information on case management issues that she can turn into a presentation or an educational tool.

Using that information, she pulled together training modules for her case managers, along with a series of 20-25 questions on each topic.

Topics include: Medicare regulations and documentation, Medicaid, one-day stays, EMTALA, acronyms used by case managers, DRGs and DRG payments, observation vs. admission status, and case management duties.

Case managers cannot finish orientation until the packets are complete.

"Some of the answers are not easy. They have to come to me or to their peers and have that dialogue. Working with their peers helps build relationships, and now they have camaraderie with the other case managers," she says.

The original case managers took longer to complete the orientation packets. Those who were hired later completed the process more quickly because they had support from their peers.

When the case managers turn in the packet, Clark sits down with them and goes over the contents.

"I want to make sure they know what they think they know. If they don't understand it the right way, I have the opportunity to fill in the gaps," she says.

Clark makes it clear to her new case managers that they have 90 days to meet her expectations.

"I tell them I am here for them and I want them to be successful, but it's their responsibility to call on me to educate them about what they don't know," she says.

Clark regularly gives the case managers handouts showing changes in policies and procedures and changes in payer regulations.

"Our business is information. The hospital pays us for what we know and how we can plug patients into what they need," she says.

Clark reviews case managers for competency on the anniversary of their hiring. What kind of raise the case manager gets depends on an annual evaluation.

"I don't wait until the year mark if they have an issue. If I see they're struggling with something, I sit down and talk with them. It gives them back their comfort level," she says.

Clark extends her educational efforts to the hospital's attending physicians, providing them with updates on payer requirements and Medicare and Medicaid regulations and how it affects the hospital.

"As I educate the physicians, the case manager's job is easier because the physicians aren't hearing it for the first time when the case managers ask them for more documentation or something else," she says.

Clark makes a presentation at the hospital's orientation session for new physicians, educating them about the role of case management and how they can help the physician and their patients.

(For more information, contact Lyn Clark, RN, BSN at e-mail: