Safety, isolation are ­drawbacks for rural CMs

Quarterly inservices make them part of the team

Case managers who live and work in rural areas often face challenges their big-city counterparts never encounter.

Safety is one drawback to having a case manager who lives in the local community and knows and is known by everyone, says Paula Casey, BSN, MSN, senior clinical project coordinator for case management at Presbyterian Health Plan (PHP) with headquarters in Albuquerque, NM.

"The good part is that everybody knows the case manager is in town. The bad part is also that they know the case manager is in town," she says.

Sometimes members who are angry with the plan or have behavioral health issues make harassing telephone calls to the case managers at all hours of the day and night.

This has prompted the case managers to be careful not to give out their last names so the members can't look them up in the telephone book and call their home number or show up on their doorsteps.

"We have to be really careful. We want a local presence, but at the same time we have to protect the safety and privacy of the case managers," adds Jean Calhoun, BSN, MSN, clinical director for case management program.

Isolation is another problem the rural case managers encounter. Unlike the Albuquerque staff, they work alone, without the advantage of colleagues with whom they can collaborate.

They've overcome it by bonding as a regional team, often calling each other to bounce ideas off each other and problem-solve together.

The health plan brings them into Albuquerque once a quarter for a two-day inservice program. The session includes training that results in continuing education units and updates on what's going on in the plan.

Calhoun and Casey also hold focus groups with the rural case managers to find out how the health plan can better serve the members and make it easier for the rural case managers to do their job.

The plan started out with monthly meetings, then switched to quarterly meetings, partly because of the cost of transportation, hotel, and food. Monthly meetings were also time-consuming and took up most of a week, leaving the case managers only three full weeks out of the month to work with their clients, Casey says.

"We negotiated with management to continue the meetings because they have really been important to the staff. These case managers feel isolated, and we feel like we need to connect to them so they'll feel like they're part of the team," she says.

PHP has a workshop every year on cultural sensitivity at a time when the regional case managers are in town.

The plan advertised in local newspapers for nurse case managers when they started their rural coverage. Since then, it's been word of mouth.

"It's an excellent job for a nurse who wants to work from her home," Calhoun says.

The case managers do have to be self-directed and accountable.

"We haven't had trouble finding them, and productivity has not been an issue," she adds.

The case managers work in home-based offices, partially funded by the health plan. They use their home offices for telephone calls and paperwork but spend a lot of their time in the community, meeting with the members.

Because of the difficulty in contacting their clients by telephone, they often meet them at the physician's office and do a follow-up evaluation.

They set up periodic time for durable medical equipment (DME) vendors to come to the area and evaluate members who need wheelchairs or other DME.

Since most DME companies are based in the city, the case managers set up periodic DME evaluation clinics to meet the local needs. They rent churches or hotel rooms and hold a daylong clinic for their clients.

The case managers attend annual provider focus groups, town hall meetings hosted by PHP in the regional areas, provider meetings, and children's clinics - anything where the plan is expected to have a presence.