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Forget on-the-job training You must have a formal orientation
It happens again and again at hospitals across America. A new case manager joins a department and receives minimal on-the-job training from another case manager who is trying to do his or her own job at the same time.
"Historically, there is a woeful lack of education for incoming case managers in a hospital environment," says B.K. Kizziar, RN-BC, CCM, CLP, owner of B.K. & Associates, a Southlake, TX, case management consulting firm.
A nurse is on the floor one day and a case manager the next day, Kizziar says. "The basic problem is that the people who end up telling the new person what their role entails became a case manager the same way," she says. "This creates a vacuum in learning and competencies."
It's not that an experienced case manager teaches a new case manager something wrong, but lack of training could result in duplication of effort or continuing to do tasks that have no value, Kizziar adds.
Teresa Fugate, RN, BBA, CCM, CPHQ, vice president, case management services for Covenant Health System, a seven-hospital system with headquarters in Knoxville, TN, says, "As case managers become comfortable in the role, they tend to forget the basics that they perform automatically, and they tend to leave them out when they're training a new person. There are so many strict compliance and discharge planning requirements that it's hard for new case managers to remember them all." For example, a seasoned case manager might forget to mention that when patients go from observation to inpatient status, the stay starts on the date and at the time the physician wrote the order, Fugate adds.
"People "don't just wake up" with the ability to perform case management, Kizziar says. "Nursing schools, social work schools, and therapy schools teach basic clinical applications," she says. Graduates have to pass an examination before they can practice, Kizziar says. "When people sub-specialize into case management, the thinking tends to be that because someone is a nurse or a social worker, they should know how to be case manager, but that's not true," she says. "It's a specialty into itself."
Case managers typically are trained in pieces that focus on the basics, Fugate says. "Then they're put on the unit and expected to know what to do. It takes at least a year of practice and additional training for a person to become competent and comfortable in performing a case management job," she says.
It's the case management leader's responsibility to make sure that new staff have the proper orientation, and often that means revising your training program, says Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management, at Lutheran Medical Center in Brooklyn, NY, and partner and consultant in Case Management Concepts, a case management consulting firm in Dallas.
Case management orientation should include didactic as well as preceptor experiences. This means you should develop classes and a collection of reading material for new case managers, as well as partnering them with a preceptor, Cesta adds.
The best time to look at your case manager training process and consider revising it is when you don't have any empty positions, suggests Beverly Cunningham, RN, MS, vice president, clinical performance improvement, Medical City Dallas Hospital, and partner and consultant in Case Management Concepts. "We all get so busy, and then we hire someone new and realize that our training and orientation process needs updating," Cunningham adds.
Before developing a case manager training program, case management directors should meet with their hospital administration and find out what the hospital expects the case management department to accomplish, Kizziar says. Design your training program around that information, she says. Develop an outline of what the hospital administration expects of the case management department, set priorities for meeting the expectations, and determine what you have to do to get it done, she says.
Cesta suggests appointing an orientation task force to develop the orientation process and update it as needed. The task force should include experienced case managers as well as those who have gone through orientation recently. Kizziar adds, "Create an orientation process so new people will have tools, instructions, and the information they need to meet the objectives, and so that each new case manager has a go-to person who also has been trained."
A successful training and orientation program should move staff members from novice to expert and from good to great, Cunningham says.
The program should include basic classroom orientation about case management in general and the particular area where the new case manager should work, followed by one-on-one mentoring from another case manager who uses a check-off sheet listing each objective that the case manager should meet, Kizziar adds.
Any curriculum should address the core competencies of case management in your department, Cunningham says. Competency measures should outline what needs to be done to demonstrate that the competency has been learned, the process followed for performing the competency correctly, and information that the case manager must have to provide effective case management, she says.
Basic competencies are those that are performed daily. Immediate competencies, such as development of case management plans, are those that are performed less frequently. Expert competencies, such as managed care contract negotiation, are performed infrequently, Cunningham adds.
"The first piece of designing or revamping a competency program is to determine what competency measures to focus on and to make sure they are measurable," she says. "The impact on the organization, the patient, and the individual should be measurable and have time-specific intervals associated with setting goals."
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Need great CM training? Focus on the basics
Adapt curriculum to experience
New case managers should have a minimum of four weeks of orientation that can be expanded if the employee needs more time, says Beverly Cunningham, RN, MS, vice president, clinical performance improvement, Medical City Dallas Hospital, and partner and consultant in Dallas-based Case Management Concepts.
The first 30 days of case manager training should focus on details such as policies and procedures, roles of case managers and social workers, information on the hospital and the software system, patient flow, and the organizational chart, Cunningham says.
Have your new employees spend time familiarizing themselves with the policies and procedures manual, and make sure it's available as a reference tool, she adds.
Adapt the orientation curriculum and educational topics to each individual employee's experience, suggests Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, and partner and consultant in Case Management Concepts. "If someone has 10 years experience, they don't necessarily need to go through the basics, but they do need to learn how things work in your hospital and on the unit to which they are assigned," Cesta says.
However, don't skip the preceptor part of orientation even if the new employee is a highly experienced case manager, she adds. "Experienced case managers still need to go through the preceptor process so they can understand how your hospital does things," Cesta says. "You might shorten the preceptor period for an experienced case manager, but you shouldn't eliminate it entirely."
During orientation, the case management director needs to have frequent contact with the new employee. Cunningham recommends that case management directors meet with new employees and the person orienting them every week and talk about how the week went and what will happen the next week. "This is a good opportunity to learn how the orientation program is going and which staff are good preceptors as well as those who might not be so effective," she says.
Never shorten the training program even if the new case manager and the preceptor are desperately needed on the unit, Cunningham advises. "Sometimes, the training process starts out with good intentions, but somebody takes medical leave and the new case manager is put out on the floor alone. It's a big mistake to look at the moment and not at the future," she adds.
If you are experiencing staff vacancies, bring in a per diem case manager so the new person can continue with their orientation, Cesta suggests. "Some case management directors may argue that they don't have the money for a per diem employee, but it will save money in the long run," she adds.
The staff chosen to orient new hires should be those who like to preceptor and who have demonstrated an ability to do it well, says Cesta, adding not all senior staff members are good preceptors. Medical City Dallas brings in an expert PRN social worker, who once worked full-time for the department, to provide orientation for new employees. Cunningham says, "When she was here, she was so good in orientation, but she had children and has transitioned to PRN to raise her family. She focuses on orientation so the new employee doesn't have to follow someone around while they do their job."
Experienced CMs? Offer ongoing training
Keep staff educated to reduce turnover
Training shouldn't stop after case managers finish the training and preceptor period. Instead, training and orienting staff should be an ongoing process, says Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, and partner and consultant in Dallas-based Case Management Concepts.
Retaining staff often is dependent on how the case manager was recruited and educated, and how the education continues after the employee is on the job, Cesta says.
"We often focus so much on the new staff that we forget the old staff," she says. "The cost of turnover is very high. There is nothing worse than investing a year in a person and having them move on."
As part of its efforts to beef up case manager training, Covenant Health System is revising its Case Management University, a comprehensive course with multiple modules, says Teresa Fugate, RN, BBA, CCM, CPHQ, vice president, case management services for the seven-hospital system with headquarters in Knoxville, TN. Every new employee in the case management department will be required to go through the training, Fugate says. In addition, Covent Health System is developing learning modules on topics that all case managers will have to complete on their own every year. The modules contain information on compliance issues and discharge planning requirements that have changed or that people tend to forget, she says.
Fugate is working with the health system's education department to develop the modules. "The basics are already there, but we're updating the information and making it more comprehensive," she says.
Hospitals have been slow to support outside education and development for case manager, particularly as it relates to professional organization, says B.K. Kizziar, RN-BC, CCM, CLP, owner of B.K. & Associates, a Southlake, TX, case management consulting firm. Few hospitals support case management certification, Kizziar adds. "A lot of the disconnection has been because hospital management doesn't appreciate the value of case management because we, as case managers, have not promoted ourselves," she adds.
The Case Management Society of America (www.cmsa.org) and the American Case Management Association (www.acmaweb.org) offer online educational opportunities for members, and both sponsor educational conferences every year, Kizziar adds. "There are a lot of online educational opportunities for case managers," she says. "Many of them are generic and aren't focused on one area of practice, but these classes give a general overview to someone who never has been in the case management arena."
Do floor nurses make good CMs? Yes and no
Explain what the job entails
Many floor nurses tend to look on case management as a glamorous job. "Case managers wear street clothes," says Teresa Fugate, RN, BBA, CCM, CPHQ, vice president, case management services for Covenant Health System, a seven-hospital system with headquarters in Knoxville, TN. "Historically, they've had weekends and holidays off. There's no heavy lifting or cleaning up patients."
Consequently, in most hospitals, when nurses on the floor make the decision to become case managers, they have no idea what they're going to be doing until their first day on the job, says B.K. Kizziar, RN-BC, CCM, CLP, owner of B.K. & Associates, a Southlake, TX, case management consulting firm. The government regulations, extensive paperwork, and attention to detail the job requires makes it a challenge for nurses to adjust to their new role, Kizziar says.
Fugate adds, "We've had people come into case management from nursing, stay 90 days, and beg to go back to nursing. All of the payer requirements and other hoops case managers have to jump through create a lot of stress, particularly for people who are accustomed to spending more time with patients than doing paperwork."
Case managers need to think on a broader scale than nurses, Kizziar says. Nurses practice hour by hour observing and evaluating patients, providing treatment, and providing direct care, she adds.
Nurses must change their focus from the plan for the day to developing a plan for the stay, while looking ahead to the discharge process, adds Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, and partner and consultant in Dallas-based Case Management Concepts. They have to make the transition from an hourly position with overtime, after-hours, and weekend differentials to a salaried position, Cesta adds.
When nurses transition into case management, they typically don't understand who the payer is, how the hospital is paid, and how what they do today impacts on the next level of care, she points out. At the same time, hiring floor nurses from your hospital has its advantages, Cesta says. "Pulling people from the bedside brings current clinical knowledge," she says. "They already have a relationship with the physicians, the rest of the staff on the unit, and an understanding of how the unit functions."
If staff nurses are interested in becoming a case manager, have them spend time with case managers before they take the job, says Beverly Cunningham, RN, MS, vice president, clinical performance improvement, Medical City Dallas Hospital, and partner and consultant in Case Management Concepts. "Most nurses on the floor have no idea of the role of the case manager even if they see them every day," Cunningham says. "It is valuable for them to spend time with a case manager so they'll understand aspects of the job they might not know about, such as trying to get information to payers."
Fugate intends to train some of the health system's staff nurses to perform PRN case management. "We want to open up Case Management University to any nurse who is interested," she says. "If they want to move into case management, they will shadow a case manager as well as going through the classes."
Fugate has requested that nursing assign new nurses to spend time in the case management department to learn how the department works and the role it plays in patient care. "We are considering having any nurses who want to become case managers to shadow a case manager for a day to better understand the job and whether it is something they want to do," she says.
When there's an empty position, evaluate the needs of the department, rather than just filling the role, Cunningham says. "The department may need a strong leader or someone who is just a good, solid case manager with no desire to take a leadership role," she says.
A good case management candidate should have a minimum of three to five years of clinical experience, be flexible, have critical thinking skills, and have good communication skills, Cunningham says. "I can teach someone utilization management, but I can't teach them how to be flexible," she adds.
Once you have identified potential candidates, arrange an interview with members of your case management team, Cunningham suggests. "The interdisciplinary team has to work with the new case manager, and they should be involved in the hiring process. There have been times when I thought a candidate was a good fit, but the staff picked up on things I missed," she says.
To earn credibility, you must dress the part
Case managers should look professional
As she consults with hospitals, B.K. Kizziar, RN-BC, CCM, CLP, occasionally is horrified by what she sees case managers wearing.
"I see case managers who come to work dressed like they should be doing yard work. Case managers don't necessarily need to wear business suits and shoes with heels, but they do need to look professional and take pride in their appearance," adds Kizziar, owner of B.K. & Associates, a Southlake, TX, case management consulting firm.
She recommends that case management attire be standardized in some way to identify the role that the case manager is performing. "People need to know that case managers are important people in the hospital who have a lot of knowledge and expertise," Kizziar says. "The best case manager in the country may be coordinating care for a patient, but if she is sloppily dressed and has dirty hair, people are less likely to trust what she says. People equate professional dress with knowledge."
Case managers need to earn credibility and respect, and that won't happen if they're wearing jeans and a T-shirt, Kizziar point out. "Credibility doesn't automatically come with a title. You have to earn that," she says.
At Covenant Health, case managers are expected to dress professionally in business casual clothing. Many of them wear lab coats as well, says Teresa Fugate, RN, BBA, CCM, CPHQ, vice president, case management services for Covenant Health System, a seven-hospital system with headquarters in Knoxville, TN. "Case management needs to be elevated, and that won't happen if the case managers don't dress professionally," Fugate says. "Business casual looks more professional than scrubs."
At one facility, case managers wear dress pants and shirts with hospital logo and "case manager" or "social worker" on the front. The shirts are available in a variety of colors. "We wanted to create an outfit that they could wear with athletic shoes because they are running all over the hospital," Fugate says.
Case management orientation should include the hospital dress code and how case managers approach their patients, Kizziar says. Case managers should avoid standing at the foot of the bed and looming over the patient, she says. Instead, they should be at the side of the bed when they talk to patients, and, if possible, sit at eye level, Kizziar says. "I see case managers walk into a patient room and say 'Hi. I'm your case manager.' They don't introduce themselves and don't call patients by name. There's not much engagement there," she says.
Peers allowed to choose among CM candidates
New hires go through rigorous training
When Jewish Hospital and St. Mary's Healthcare, a health system in Louisville, KY, has an opening in the care management department, the final decision to hire a candidate is made by a team of peer interviewers.
"These are the people who are going to be working with the new care manager. They are trained on peer interviewing to ask the kind of questions that help them determine which candidates are right for our department," says Bev Beckman, RN, ACM, CPHQ CHAM, corporate director of care management at the not-for-profit health system. The system includes a 442-bed tertiary care regional referral center and a 192-bed community acute care hospital.
After they are hired, the new employees go through a two-day hospital orientation and five weeks of training with a dedicated preceptor in the care management department. They must pass a series of competencies and tests before they can work on their own.
"It's rare to find an experienced care manager," Beckman says. "It's necessary to develop an excellent training program for the right person for the department. If they come from another hospital, they may have performed the same tasks but in a different way, so they still have five weeks of orientation."
When a care management job becomes vacant, she posts the job internally and on the hospital's web site and CareerBuilder.com. While Beckman prefers to hire experienced case managers, that type of hiring happens only about 10% of the time. Most of her new hires are floor nurses who want to become care managers. "It's rare to find care managers who move from hospital to hospital," Beckman says. "What I find are people who want to become care managers. If I can find the right people, I'm willing to make an investment and train them."
She gives preference to nurses with a BSN degrees and five years of clinical nursing experience, preferably in the intensive care unit or emergency department. "Nurses with backgrounds in the ICU or ED understand more of the big picture," Beckman says. "I always look for people who can multi-task, who have good computer skills and good interpersonal skills."
She reviews all the applications and schedules a screening interview with the candidates who meet her criteria. Beckman selects two or three good candidates to move on to the peer interview process.
A team of care managers trained in peer interviewing conduct the final interview, score the candidates based on their responses, and make the final selection. They ask questions they developed to give them an idea of the candidates' communication skills, adaptability, team work, ability to exercise initiative, conflict management skills, and engagement ability. For example, to judge communication skills, the peer interviewers ask the candidate to describe a time when they had to sell an idea or a plan to a patient and family. Under the category of conflict management, they ask the candidates to talk about a how they overcame a difficult experience with a physician, a patient, or a family member.
Each member of the peer interview team scores the candidates on all the questions. Whoever scores the highest is offered the job. "The team interviews the candidates and selects someone they can work with and who will fit into the department," Beckman says.
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New CMs receive class, preceptor education
Learning to manage cases on their own
New case managers at Jewish Hospital and St. Mary's Healthcare in Louisville, KY, go through a rigorous training process that includes classroom education, meetings with representatives of departments that work with case management, and five weeks of training with a preceptor.
The care management department's preceptor is an accredited case manager who has been trained as a preceptor. When she is training a new employee, her only responsibility is to be a preceptor. When she is not training, she is a case manager on the floor.
"It is very important to have dedicated preceptors. It's not effective to bring in new people and have them trained by multiple individuals. By having one preceptor do all the training, the teaching is consistent," says Bev Beckman, RN, ACM, CPHQ CHAM, corporate director of care management at the not-for-profit health system that includes a 442-bed tertiary care regional referral center and a 192-bed community acute care hospital.
During the first week, the care manager and preceptor go over the care management process, the daily routine on the nursing unit, the department's walking rounds, discharge planning, the department's computer system, the care manager's role in core measures, and the denial management process.
The preceptor shows the new employee how to perform an initial assessment and review each day for medical necessity, use InterQual and Milliman, determine patient status, work with the physician on documentation, interact with the company that performs second level physician review, evaluate and screen patients, and make a referral and follow through. "Our goal is to teach the practice of care management," Beckman says. "It takes us years to learn to be nurses, and it also takes a certain amount of time to become a competent care manager. We teach them the standards of practice and how to execute them within our hospital system. The teaching is the same for everybody."
The department has developed its own training manual and has a shared drive on the computer system with all the forms and procedures the case managers use. "Care managers should never have a question about what we do because all our practices are on the shared drive," Beckman says.
As part of orientation, the new care managers meet for two to three hours with a social worker, the rehabilitation coordination, and a financial counselor. The new care managers spend time observing in the resource center with LPN payer specialists who provide remote denials management and utilization review services for the two acute care hospitals.
Beckman spends about three hours with the employee. "I talk to them about our philosophy and the practice of case management," she says. "When I meet them, I talk about our care management model; our mission, goals, and objectives; and how we are integrated with the organization's philosophical framework. I go over the job description and role, annual performance evaluation, work schedule procedures, time and attendance, vacations, and breaks."
The new employees spend a day in the classroom for computer education and begin working cases in increments. The first week, after the preceptor has covered some of the details on how the department works, the new care manager is assigned three to five cases. The number of cases increase to up to seven during the second week, up to 15 the third week, and up to 20 cases on week four.
"On week five, we put them on the unit where they're going to work," Beckman says. "The preceptor is available but lets the care manager work independently. The preceptor is there to shadow the care manager and to be available if any questions arise."
Before they can work independently, new care managers have to demonstrate competency in all tasks and pass all tests. The department has developed a comprehensive competency check-off list for all tasks that for which care managers have responsibility. Then they take a 38-question online competency test that includes the full scope of everything they have learned and an online InterQual test where they are asked to review case scenarios and determine patient status and level of care. They must complete an online module on the Hospital-Issues Notice of Non-coverage (HINN) and another module during which they demonstrate that they can identify the necessity for and complete a Condition Code 44 document.
"All our care managers have a toolkit that includes a laptop computer with access to our share drive, an orientation guide, and our training manual," Beckman says. "They are linked to the preceptor forever and are encouraged to ask anyone on the team for assistance."