Case Management Advisor

Handling the transition from staff nurse to case manager

By Toni Cesta, PhD, RN, FAAN
Senior Vice President
Lutheran Medical Center
Brooklyn, NY

In October's edition of Case Management Insider, we discussed the importance of using good recruitment and retention strategies in the case management department. Because recruitment is an essential component of retention, this month we will focus on the next generation in case managers: the staff nurses!

Staff nurses are a logical "next generation" for case management. They bring many of the skill sets that contemporary case managers need in order to be effective in their roles. The newest case management models incorporate many roles and functions that are dependent on a strong clinical foundation. Patient flow, coordination and facilitation of care, transitional planning, and resource and utilization management all depend on a strong clinical base from which to draw knowledge to use in working as a case manager in the acute care setting. In fact, when recruiting staff nurses, consider making a match between their clinical areas of expertise and the unit where they will work as case managers. Matches such as this one can make a big difference in their success as they transition into their new role.

Staff nurses bring additional skill sets to the role of case manager. In addition to their clinical base, they bring a familiarity and knowledge of the acute care setting. They know their way around multiple hospital departments and systems that make up today's acute care environment.

They also understand the process of clinical coordination and facilitation of care. They understand coordination of care from the perspective of the daily care interventions that a patient needs and the efforts necessary to ensure that things happen in an organized and clinically appropriate progression.

For many staff nurses, they are moving from an hourly position to a salaried position. This shift might mean more flexibility in their schedule and the ability to use their time to more greatly meet the needs of their patients.

With the change to case manager, there also might be some concerns for the staff nurse. Being salaried means that they are no longer eligible for overtime, weekend, or holiday differentials or other sources of additional income. So being salaried can be a negative as well as a positive. In addition, while staff nurses are adept at planning for the patient's day, they might be less skilled at planning for the patient's entire hospital stay and beyond. Because many staff nurses work 12-hour shifts, they might never have developed the skill sets necessary to coordinate care beyond a one-day focus. The acute care case manager must think about today, tomorrow, the day of discharge, and the services the patient will need in the community.

Case managers must be skilled at negotiating with patients, families, physicians, insurance companies, outside agencies and vendors, as well as other hospital departments. This skill set might not be one that they have developed and might raise some concerns from those less comfortable in the art of negotiation. However, learning these skills can be done!

It is highly unlikely that the average staff nurse, coming directly from the bedside, has knowledge in utilization management, discharge planning, transitional planning, Medicare and Medicaid regulations, or other similar elements necessary to be successful in the role of case manager.

Evolving to the case manager position

New case managers must learn to change their focus from a strictly clinical one, to one that incorporates clinical issues balanced with financial and regulatory issues.

The case manager must constantly find a balance between the patients' clinical needs, their healthcare insurance coverage, and other financial concerns. This broader healthcare world view takes time to understand and incorporate into daily practice. The complex role of the case manager requires an ability to be extremely flexible as each day's focus is variable.

Time management and organizational skills must be viewed from a different perspective. As a staff nurse, the day's routine is dictated by medication administration, physical assessments, rounding, and so on. These activities are structured and dictated by specific time intervals.

The day in a life of a case manager is significantly different. One day might be focused on negotiating with a third party payer; another day might be consumed with a complex discharge plan. Some days might involve lots of discharges, while other days could be many admissions. Case managers must quickly learn to adjust as needed and to remain flexible at all times. Time management is a skill that is intensely needed, and some staff nurses might find this aspect of the job overwhelming at first.

Case managers, unlike staff nurses, must extend their communication skills far beyond the walls of the hospital. They must learn to communicate with third party payers, continuing care providers including nursing homes, home care agencies, durable medical equipment companies, city and state agencies, and multiple other options and services. Good communication skills, in addition to an ability to switch from one task to another quickly, are essential to the role. Collaborating with healthcare providers across the continuum takes time to understand and master. It is not learned in nursing school, and it might take time for some to master.

Collaboration must take place inside the hospital as well. Case managers must collaborate and communicate with virtually every department and discipline. The emergency department, medical records, radiology, housekeeping, patient transport, laboratory, and finance are just some of the departments with which case managers have to work. In addition, they have to collaborate with other disciplines including physicians, staff nurses, social workers, physical therapists, respiratory therapists, and others.

As a case manager, you must be familiar with different sets of standards from The Joint Commission, such as patient flow, hand-off communication, and discharge planning. Centers for Medicare and Medicaid Services Conditions of Participation for Medicaid and Medicare also must be understood. Case managers need to understand healthcare reimbursement, how managed care contracts work, and the list goes on.

Data entry and interpretation is another skill set needed by the case manager in today's hospital. Basic computer skills are a must. For example, many case managers are asked to identify avoidable delays and enter them into their case management software program.

At least 50% of hospitals today have some type of electronic repository for case management data and information. This data is easily accessible, retrievable, and reportable. Therefore case managers must have a working knowledge of how to enter data and navigate through these programs.