Feeling frustrated and challenged by your job? You’re not alone
Feeling frustrated and challenged by your job? You’re not alone
Changing roles mean a shift in outlook
In today’s health care arena, case management duties and job descriptions are changing rapidly, often resulting in feelings of frustration and disconnection among case managers in the managed care industry.
"Case managers on the payer side have always felt somewhat disconnected because, primarily, their contacts with clients are by telephone," says Sandra Lowery, RN, BSN, CRRN, CCM, CNLCP, president, Consultants in Case Management Intervention, a Francestown, NH, health care consulting firm specializing in case management.
In the past decade, the case management arena has shifted from on-site case management to more telephonic case management.
The problem has been exacerbated in recent years because of caller ID, do-not-call lists, and increased insurer distrust that make it more difficult than ever to reach their clients, Lowery reports.
"This is another challenge because they feel more disconnected. When they are calling clients, they don’t necessarily reach them," she says.
At the same time, case managers in the managed care industry are being asked to do other jobs instead of case management, including quality improvement initiatives and disease management roles, such as health coaching, that are not a traditional part of the case management role. They must learn new skill sets, such as predictive modeling and motivational interviewing and are being asked to do more data entry and analysis than in the past.
"There has been a huge leap in terms of the identity of the case management role, and the new skills that case managers need are a big challenge," Lowery adds.
Case managers should make sure their employers are aware of the national standards of practice for case management and base the case management role on those standards.
"Case managers should make sure that there are separate job descriptions for the different hats they wear. If they’re doing disease management and not case management, they should make sure that there is a job description for what they do," she says.
Case managers have told B.K. Kizziar, RN, CCM, CLCP, that they are so pressed with other tasks that they don’t have the time to build relationships with their clients.
"The case management job has become more task-oriented than process-oriented, whether it’s due to the legal requirements, accreditation requirements, or the requirements of the governing entity. Case management has lost that patient relationship piece and has become mostly about data collection," says Kizziar, owner of BK & Associates, a case management consulting and life care planning company based in Southlake, TX.
That’s what Marcia Diane Ward, RN, CCM, experienced when she decided to return to case management after a career in information technology.
"When I pioneered as a managed care case manager in the late 1980s, insurance companies seemed to value nurse case managers and to realize that they bring a wealth of information to the table. The focus was always cost-oriented; but in the old days, there was more respect for nurse case managers as a professional and an educated decision maker," she recalls.
When Ward began interviewing at managed care companies, she found that the case management role had changed. She took a job with a major firm but left a month later after spending much of her time negotiating out-of-network fees.
"Basically, case managers are just managing the benefits. They are making sure patients get out of the hospital on time and looking at length of stay. These are case management functions, but it seems to be very unimportant to the managed care organizations for the case managers to have direct contact with the patient. They tend to see it as a waste of time," Ward explains.
One potential employer told her that if she did get in touch with patients, she was to use a script that they provided.
"This leaves no room for the nurse case manager’s judgment. Case managers used to manage their own cases. It’s a great reward when we can have good coordination of care, good outcomes, and save money along the way," she says.
If health plan members know to ask for a case manager and do so when the need arises, the impetus will be on the managed care organizations to put the role of patient advocate back into the case management job description, Kizziar points out.
"The future of case management universally depends on our ability to build relationships with the community. The highest form of advocacy is to inform the public of our services. If people don’t know what a case manager is and what services they provide, they don’t know to ask for one," she says.
When Kizziar develops programs for providers, she promotes the idea of telephonic contact with the insured on a routine basis.
"I do a lot of case management program development and always emphasize that we can be more successful in meeting our objectives by creating and nurturing relationships with patients," she adds.
Part of the case manager’s role as an advocate is to educate clients as to what their benefits are and how they can best use them.
"The opportunity to build a relationship on a positive note gives the case manager an element of satisfaction they don’t get through e-mail, voice messaging, or paperwork," Kizziar explains. "We’re such a techno-savvy and techno-reliant industry that we have a tendency to spend a great deal of time on the latest technology that can save us time. In many cases, we’ve taken the patient out of the equation," she laments.
Often, the first time the insured hears from a case manager is with bad news, that the treatment their physician has recommended isn’t covered by their benefit, Kizziar says.
"We’ve come a long way in changing the perception that the only things payers want to do is cut benefits and save money, but when we take the personal relationships out of it, you’ve lost a significant piece of what health care can be about," she adds.
When case managers take the time to let a member know who they are, giving them a name and a phone number and checking back with him or her routinely, it builds a relationship that may prevent resentment when the benefit won’t cover something. "If the insured knows who we are, if they hear a voice and have a name, the ability to change behavior in disease management increases because they’re talking to someone they know, rather than an anonymous caller," Kizziar says.
Today’s case managers are doing far more than in the past, with increasing caseloads to boot, Lowery says.
They are working with predictive modeling tools, and their work is geared toward primary prevention as well as secondary prevention of chronic diseases.
Many case managers are very frustrated with the new skill sets that their job requires, such as health care coaching to prevent exacerbation of chronic diseases, Lowery says.
"Coaching has always been a part of case management, but it’s now on a different level," she says.
Insurance companies are providing training for motivational interviewing and health coaching, but the training is usually short and doesn’t give the case managers the skills they need for the job, Lowery says.
"Four hours of training isn’t enough. This is a whole new skill case managers need to acquire and not one they got in nursing school. Companies should realize that some people are not comfortable with that function and may need some mentoring beyond training," she says.
Caseloads continue to be a major challenge for case managers, Lowery says.
"We don’t have any national benchmarks, so each organization tries to interpret blindly what the caseload should be," she says.
Since there are few benchmarks for caseloads, encourage your organization to do time studies in order to base caseload assignments on objective information and to base caseloads on the acuity levels of the members being managed, she adds.
Case managers should remember that their main role is that of advocate and educator, Kizziar says.
"Over and over again, when I talk to case managers I ask how many know how many home health visits their benefits allow or what the annual dollar benefit for home health is. Rarely do more than 1% or 2% raise their hands. If we, as case managers and health care professionals, don’t know our benefit, how can we expect our clients to know?" she asks.
While case managers need to be computer-savvy and understand the nuances of today’s health care arena, they also need to develop good communication skills in order to do their jobs well, Kizziar says.
In todays health care arena, case management duties and job descriptions are changing rapidly, often resulting in feelings of frustration and disconnection among case managers in the managed care industry.Subscribe Now for Access
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