Want to spend more time interacting with patients?

Here are two opportunities to consider

Case managers went to nursing school to take care of people, something they find themselves doing less and less in most practice settings, Catherine Mullahy, RN, BS, CRRN, CCM, points out.

"Nurses like to feel like they are making a difference for patients, that they are part of the solution to their patients' health care issues. Case managers who spend a huge amount of time with their heads in a chart or talking to insurers aren't feeling good about what they are doing. Instead of spending time with patients, they're spending time on paperwork and business issues," adds Mullahy,president and founder of Mullahy & Associates, a case management training and consulting company.

In the future, as people need more and more help navigating the health care system, case managers are going to have the opportunity to have much more personal and face-to-face contact with patients, she says.

Direct-to-consumer case managers and guided care nurses already are providing face-to-face case management and developing a close relationship with their clients, she adds.

Guided care nurses

Guided care nursing gives RNs an opportunity to do what they went to nursing school for in the first place, says Kathleen Trainor Grieve, RN, BSN, MHA, CCM, a guided care nurse from Johns Hopkins Healthcare who works at Johns Hopkins Community Physicians at White Marsh.

The guided care model was developed by an interdisciplinary team of clinical researchers at Johns Hopkins University to improve the quality of life and efficiency of resource use for people with complex medical conditions.

Guided care nurses work in the primary care setting to coordinate care for patients with chronic conditions and complex needs, working side by side with the primary care physician, and interact with other health care providers who treat their patients.

"We are partners with the primary care physicians, the patients, the families, and the specialists. We take a holistic approach to patient care and are truly part of the whole team," she says.

Unlike nurses in other settings, guided care nurses never lose track of their patients after a brief episode of care because they work with their patients on a long-term basis, usually for life, Grieve points out.

They develop a close working relationship with patients and their caregivers and meet with them in their homes as well as accompanying them to physician visits and visiting them in the hospital. They coordinate transitions between levels of care and providers.

"Some patients have said that working with a guided care nurse is like having a nurse in the family. Someone they trust is looking out for them and getting them the care they need," Grieve says.

Following an at-home assessment and evidence-based planning process, the guided care nurse monitors patients proactively, promotes self-management, smoothes transitions between sites of care, educates and supports family caregivers, facilitates access to community resources, and coordinates the efforts of health care professionals, institutions, and community agencies.

"Self-management is an important aspect of the program. We don't do things for our patient that they can do for themselves. We focus on helping them take charge of their own health," she says.

Guided care nurses come from a variety of backgrounds, Grieve says. Of the seven nurses in a three-year trial of the guided care nurse program at Johns Hopkins, one nurse had geriatric experience, another was an experienced home care nurse, and another had been a hospital-based nurse for only four years.

"It's not so much the experience nurses have had that make them a successful guided care nurse. It's their personal attributes," she adds.

For instance, guided care nurses have to be assertive when they need cooperation from the physicians, especially when they are just starting with the practice.

"Doctors are all overworked and have limited time. You can't let it stop you when they tell you they don't have time to talk," she says.

Guided care nurses must complete a guided care nursing curriculum and pass a certification examination.

Direct-to-consumer case managers

Direct-to-consumer case managers are nurses who are independent business owners and contract with patients and/or their family members.

While the contract for the actual services may be with the patient, referrals may come from group medical practices, elder care attorneys, financial advisors, small employee groups, and others who are aware of the benefit of the services.

Their fees are paid by the person who hires them.

"There's a tremendous need for case managers to help consumers navigate the health care system. Direct-to-consumer case managers help patients understand their diagnosis, their treatment plan, their medications, and help when nobody else has the time to answer their questions. They are the patient's advocate and someone patients and family members can call on when they have questions and concerns," Mullahy says.

When patients are seeing five or six different doctors, they need a case manager who can go with them to their appointments, help coordinate the care, and ensure that all of the providers have the information they need to develop a treatment plan.

"This type of practice gives case managers an opportunity to work one on one with patients and to develop a close relationship with them. It goes back to the first generation of case management where the case managers spent time with their patients. Direct-to-consumer case managers can control their own caseload and decide the best way to handle their cases," she says.

Direct-to-consumer case managers are not employed by a managed care organization, a hospital, or another entity.

"They represent the patient's interest and only the patient's interest. They don't face the challenge that their employer may want something that conflicts with what they think is the patient's best interest," Mullahy says.

Geriatric case managers have been contracting with family members or elder care attorneys for a number of years and managing the care of elderly patients, often when their family members live in another state, Mullahy says.

Other case managers have gone into business to consult with patients who are undergoing cancer treatment or have complicated conditions, such as congestive heart failure or end-stage renal disease, she adds.

Direct-to-consumer case management is a growing field that is likely to increase in the future, but it's not for everyone, Mullahy says.

"Just because someone is a wonderful case manager, they don't necessarily have what it takes to become a business owner and market their own services," she adds.

Offering your services as a consultant to consumers is fulfilling but is challenging because many case managers can't afford to go out on their own and lose the security of a weekly paycheck, she says.

Mullahy advises case managers who would like to try direct-to-consumer case management to keep their job and build up their practice in their spare time.

"I wouldn't advise anyone to leave the security of a job unless they have savings and other income," she says.

(Johns Hopkins is offering a six-week, 40-hour online guided care nurse course through the Institute of Johns Hopkins Nursing. For more information, visit www.ijhn.jhmi.edu.)