MSN6610 – The Nurse’s Role in Care Coordination: Activity Log
MSN6610 – The Nurse’s Role in Care Coordination: Activity Log
Activity Log
Session 1
Characters selected to interview
Seth Patterson
Case Manager
Lucas Branch
Diabetes Educator
Vicki Vasquez
Director of Case Management
Samantha Rockwell
Social Worker
Orientation Interviews
Seth Patterson
Case Manager
Can you please describe your role in the department?
I coordinate care for all kinds of people in the hospital. They tend to give me cases
involving older adults, since that’s my background, but for the most part all the case
managers need to be equipped to work with all kinds of cases. I worked with
geriatric patients almost exclusively with another hospital. Other case managers
come to me sometimes when they need geriatric resources or have questions
about how to help elderly patients.
MSN6610 – The Nurse’s Role in Care Coordination: Activity Log
In your opinion, what are some of the most important things a new case manager needs to know?
Here’s a tip: make yourself a master list of phone numbers! I can help you get
started with that. After a while, you figure out who to call at each insurance
company when you really need to get something done, or who to call at various
social service agencies to get accurate information about resources, and so forth. I
can’t even tell you how much time my list saves me!
What are some of the biggest mistakes case managers make?
One of the biggest problems case managers have is with coordinating transfers
from one facility to another–especially when you’re talking about older adults,
because moving them can be very risky. When patients go to the wrong facilities,
that can be traumatic for the patient and costly for the hospital. It’s important to do
your research and find the best possible facilities for patients so they don’t have to
be moved again. That can be a real challenge because of insurance issues… ugh!
It’s incredibly frustrating when the best facility for someone isn’t covered by
insurance. But that’s just part of our jobs…. negotiating stuff like that with insurance
companies on behalf of our patients’ best interests. It’s also really important to
figure out whether sending somebody home is a good idea. Sometimes home
health care is the best solution, but sometimes it’s not, depending on the family
situation and all kinds of factors you need to consider.
In your experience, how has care coordination changed?
Dealing with insurance companies and Medicare and federal regulations and all of
that… it just gets more complicated all the time. I like to think that I’m an advocate
for our patients, helping them navigate through all this red tape and regulation. If
it’s this hard for me to navigate things, I can only imagine how hard it is for the
patients–especially if they’re elderly or have language barriers and stuff like that.
What are the some of the most important trends in care coordination?
Electronic medical records are revolutionizing what we do. And overall this is a
good thing. I mean, a big part of what we do is to try to prevent fragmentation of
care, and EMRs make a world of difference with that. On the other hand, as
someone who’s worked with elderly people, I know what a problem EMRs can pose
to patients who aren’t technologically literate. I’ve heard and seen horror stories.
One of the nurses at a clinic where I used to work, she told me about this elderly
woman who had elevated blood sugar levels. Her manager wouldn’t let her call the
woman to get a retest because the clinic wanted to push people into using the new
patient portal. You know, because of meaningful use issues? If enough people
didn’t use the portal, the clinic could lose funding. Well, this woman was in her 80s,
and lo and behold, she never looked at her electronic record and wound up at the
hospital with a blood sugar level over 600!
MSN6610 – The Nurse’s Role in Care Coordination: Activity Log
Lucas Branch
Diabetes Educator
Can you please describe your role in the department?
I work with case managers to make sure that patients get the information they need
about diabetes care and prevention. When appropriate, I provide patients with
resources to help them manage their diabetes. Often I help patients who are
diagnosed with a chronic condition and who also have diabetes, since that new
condition might mean they have to make changes in their diabetes management
plan. I also talk with patients who have prediabetes or risk factors.
In your opinion, what are some of the most important things a new case manager
needs to know?
From my perspective, case managers need to be aware that it’s critical to provide
patients with accurate information–and explain to them how to use it. With
diabetes, there’s so much misinformation out there. Some patients underestimate
the danger of diabetes and think it’s no big deal. Others are completely terrified and
think it’s a death sentence, and they don’t realize they have the power to manage
- And that’s true of other medical conditions as well. People rely way too much on
Dr. Internet to get the information they need. A case manager needs to make sure
that patients have real information they can use.
What are some of the biggest mistakes case managers make?
As a team, it’s so important to do everything we can to prevent fragmentation of
care. Fragmentation brings costs up and quality down, and it can be really
dangerous. We need to make sure patients aren’t getting conflicting information or
medication from different providers.
Vicki Vasquez
Director of Case Management
Can you please describe your role in the department?
Well, the part of my job that I like the most is serving as a role model and mentor to
the team members in this department. I’ve worked in care coordination for a long
time. So if someone feels like they’re up against a brick wall and can’t figure out
how to help a patient, I can put on my coach hat. I enjoy that. A more challenging
part of my job is working with the bureaucracy to make sure that patients get what
they need and that the hospital gets paid. Health care law and regulations change
all the time. You’ll be shocked at how much they change. As the leader of this
department I have to make sure I’m 100% on top of these changes–especially
since St. Anthony is an Accountable Care Organization. The hospital is constantly
evaluated on 33 quality indicators, and our ability to manage complicated cases is
essential if we’re going to keep our rank up.
Samantha Rockwell
Social Worker
Can you please describe your role in the department?
I consult with case managers to make sure that they’re considering all the social
issues that impact a patient’s ability to get the care they need and to manage their
care. I meet with patients and find out what’s going on in their lives… their financial
situations, their family situations, possible barriers to care, anything really that
might impact their ability to get care. I also work with case managers to help locate
appropriate resources for clients.
Patient Meeting
Panel participants
Samantha Rockwell
Social Worker
Lucas Branch
Diabetes Educator
Vicki Vasquez
Director of Case Management
Seth Patterson
Case Manager
MSN6610 – The Nurse’s Role in Care Coordination: Activity Log
Panel Q & A
Let’s hear what your new colleagues have to say about this patient.
Vicki: So, Seth, you were the case coordinator who was working with Mr. Decker and his
family. Can you tell me what happened?
Seth: Well, as you know, Mr. Decker came in with a badly infected toe. He was diagnosed
with diabetes last year. It sounds like he hasn’t been treating it effectively.
Vicki: Why do you say that?
Lucas: I spoke with Mr. Decker and his wife. It sounds like he’s been forgetting to take his
insulin. He said that’s only happened twice, but I got the sense from his wife that it
happens fairly often. Plus they both told me his diet hasn’t changed much since the
diagnosis. He’s lost about 10 pounds, which is great. But he’s still in the obese range.
Vicki: That’s too bad. Was the diabetes related to the toe infection?
Seth: It was probably a factor. He cut his toe while walking his dog. His wife washed the
cut and put a bandage on it. But it got worse. A nephew finally took him to his primary
physician, since he and his wife don’t drive on freeways anymore. The physician sent Mr.
Decker to the hospital.
MSN6610 – The Nurse’s Role in Care Coordination: Activity Log
Vicki: So explain to me what happened when Mr. Decker came here the first time.
Seth: Mr. Decker was given antibiotics and the infection started to clear up after a two-day
stay. Medicare wanted to send him home with antibiotics. We weren’t aware that his toe
wound had progressed and he had developed a more resistant infection.
Vicki: That’s too bad. Samantha, what was your involvement in this case?
Samantha: I met with Mr. and Mrs. Decker. I was definitely concerned that Mr. Decker
wouldn’t take the antibiotics if we sent him home. He also needed to treat the infection site
twice a day. Mrs. Decker assured us that us that she would take care of her husband and
make sure the infection was treated. But I was leery because it doesn’t sound like the
diabetes or the original cut was treated very well.
Vicki: So why was he sent home?
Seth: Well, for one thing, we talked to the Deckers’ nephew–the one who drove him to the
doctor and the hospital. He said that his wife was a stay-at-home mom and that she could
stop by twice a day to take care of Mr. Decker. Apparently this couple lives in the same
neighborhood as the Deckers. Also, the Deckers’ daughter was planning to fly in from
California later that week to take care of him.
Vicki: Did that happen?
Seth: No. Apparently there was a last-minute emergency at the daughter’s workplace, so
she wasn’t able to come. And it’s unclear to me how often the nephew and his wife
stopped by.
Samantha: Yeah. I spoke with the nephew. Apparently his wife wasn’t happy about being
volunteered for this situation. It sounds like she only stopped by a few times.
Vicki: So now Mr. Decker is back. It sounds like he is responding well to the new round of
antibiotics.
Seth: Thankfully, yes. At first we thought an amputation might be necessary. But he’s
doing remarkably well. He might be able to go home next week–except that we know
that’s not a realistic option.
Vicki: So what’s next?
Samantha: The Deckers don’t have the resources to pay for much that Medicare won’t
cover. A rehabilitation center might be a good option, but it will be a challenge to find one
they can afford. Other options would be home health care or an outpatient infusion center.
Vicki: Seth and Samantha, what are your thoughts about the outpatient infusion center?
Seth: At this point, I think that’s the best option. Mr. Decker doesn’t need rehabilitation. He
just needs someone to administer the antibiotics.
Samantha: I actually think a skilled nursing facility might be the better option. We’ve seen
that the Deckers aren’t able to handle this themselves, and that they don’t have a good
enough support system to help. The infusion center would only help with the antibiotics.
We need to make sure the infection site is cared for and that he gets some help with his
diabetes as well.
MSN6610 – The Nurse’s Role in Care Coordination: Activity Log
Seth: But that’s an expensive option they may not be able to afford–and I don’t think that
level of care is necessary.
Samantha: But I just can’t picture sending Mr. Decker home yet. I’m afraid he’ll wind up
back here again–or worse.
Patient Meeting Debrief
Denise McGladrey
Preceptor
Send him to a rehabilitation facility.
That’s certainly one option. But what if the Deckers can’t afford it?
Research options. Look for a rehabilitation facility that they can afford.
I would definitely do this. It sounds like Mr. Decker might not do so well at home
yet. Make some phone calls. However, be prepared for the possibility that they
won’t be able to afford a rehabilitation facility. You’ll need to consider other options
as well–like an outpatient infusion center.
No. he should have stayed in the hospital.
That might have been the best choice if it weren’t for financial considerations. The
hospital can’t keep people here indefinitely. Can you think of some other
alternatives?
A home health care service should have been investigated.
That’s a good idea. It might not have been affordable, but I agree that option could
have been explored. There was enough evidence that Mr. Decker and his wife
were not able to care for his infection alone, and no proof that anyone reliable was
available to help them.
Session Notes
You did not enter any notes for this session.
MSN6610 – The Nurse’s Role in Care Coordination: Activity Log
Session 2
Characters selected to interview
Seth Patterson
Case Manager
Lucas Branch
Diabetes Educator
Vicki Vasquez
Director of Case Management
Samantha Rockwell
Social Worker
Orientation Interviews
Seth Patterson
Case Manager
Can you please describe your role in the department?
I coordinate care for all kinds of people in the hospital. They tend to give me cases
involving older adults, since that’s my background, but for the most part all the case
managers need to be equipped to work with all kinds of cases. I worked with
geriatric patients almost exclusively with another hospital. Other case managers
come to me sometimes when they need geriatric resources or have questions
about how to help elderly patients.
In your opinion, what are some of the most important things a new case manager
needs to know?
Here’s a tip: make yourself a master list of phone numbers! I can help you get
started with that. After a while, you figure out who to call at each insurance
company when you really need to get something done, or who to call at various
social service agencies to get accurate information about resources, and so forth. I
can’t even tell you how much time my list saves me!
What are some of the biggest mistakes case managers make?
One of the biggest problems case managers have is with coordinating transfers
from one facility to another–especially when you’re talking about older adults,
because moving them can be very risky. When patients go to the wrong facilities,
that can be traumatic for the patient and costly for the hospital. It’s important to do
your research and find the best possible facilities for patients so they don’t have to
be moved again. That can be a real challenge because of insurance issues… ugh!
It’s incredibly frustrating when the best facility for someone isn’t covered by
insurance. But that’s just part of our jobs…. negotiating stuff like that with insurance
companies on behalf of our patients’ best interests. It’s also really important to
figure out whether sending somebody home is a good idea. Sometimes home
health care is the best solution, but sometimes it’s not, depending on the family
situation and all kinds of factors you need to consider.
In your experience, how has care coordination changed?
Dealing with insurance companies and Medicare and federal regulations and all of
that… it just gets more complicated all the time. I like to think that I’m an advocate
for our patients, helping them navigate through all this red tape and regulation. If
it’s this hard for me to navigate things, I can only imagine how hard it is for the
patients–especially if they’re elderly or have language barriers and stuff like that.
What are the some of the most important trends in care coordination?
Electronic medical records are revolutionizing what we do. And overall this is a
good thing. I mean, a big part of what we do is to try to prevent fragmentation of
care, and EMRs make a world of difference with that. On the other hand, as
someone who’s worked with elderly people, I know what a problem EMRs can pose
to patients who aren’t technologically literate. I’ve heard and seen horror stories.
One of the nurses at a clinic where I used to work, she told me about this elderly
woman who had elevated blood sugar levels. Her manager wouldn’t let her call the
woman to get a retest because the clinic wanted to push people into using the new
patient portal. You know, because of meaningful use issues? If enough people
didn’t use the portal, the clinic could lose funding. Well, this woman was in her 80s,
and lo and behold, she never looked at her electronic record and wound up at the
hospital with a blood sugar level over 600!
Lucas Branch
Diabetes Educator
Can you please describe your role in the department?
I work with case managers to make sure that patients get the information they need
about diabetes care and prevention. When appropriate, I provide patients with
resources to help them manage their diabetes. Often I help patients who are
diagnosed with a chronic condition and who also have diabetes, since that new
condition might mean they have to make changes in their diabetes management
plan. I also talk with patients who have prediabetes or risk factors.
In your opinion, what are some of the most important things a new case manager
needs to know?
From my perspective, case managers need to be aware that it’s critical to provide
patients with accurate information–and explain to them how to use it. With
diabetes, there’s so much misinformation out there. Some patients underestimate
the danger of diabetes and think it’s no big deal. Others are completely terrified and
think it’s a death sentence, and they don’t realize they have the power to manage
- And that’s true of other medical conditions as well. People rely way too much on
Dr. Internet to get the information they need. A case manager needs to make sure
that patients have real information they can use.
What are some of the biggest mistakes case managers make?
As a team, it’s so important to do everything we can to prevent fragmentation of
care. Fragmentation brings costs up and quality down, and it can be really
dangerous. We need to make sure patients aren’t getting conflicting information or
medication from different providers.
In your experience, how has care coordination changed?
That’s a better question for someone like Nora, who’s been working in this field for
so much longer than me! But even in the short time I’ve been here, I can see how
much more care goes into managing patient transfers. We do a lot more
investigating now to make sure patients are going to the right facilities.
What are the some of the most important trends in care coordination?
The team mentality has made a really big difference. The idea that you bring in a
diabetes educator, you bring in a dietician, you coordinate with a social worker….
that kind of interdisciplinary thinking leads to much better outcomes.
Vicki Vasquez
MSN6610 – The Nurse’s Role in Care Coordination: Activity Log
Director of Case Management
Can you please describe your role in the department?
Well, the part of my job that I like the most is serving as a role model and mentor to
the team members in this department. I’ve worked in care coordination for a long
time. So if someone feels like they’re up against a brick wall and can’t figure out
how to help a patient, I can put on my coach hat. I enjoy that. A more challenging
part of my job is working with the bureaucracy to make sure that patients get what
they need and that the hospital gets paid. Health care law and regulations change
all the time. You’ll be shocked at how much they change. As the leader of this
department I have to make sure I’m 100% on top of these changes–especially
since St. Anthony is an Accountable Care Organization. The hospital is constantly
evaluated on 33 quality indicators, and our ability to manage complicated cases is
essential if we’re going to keep our rank up.
In your opinion, what are some of the most important things a new case manager
needs to know?
There’s a lot you need to know to be an effective case manager. One of the most
crucial skills is problem solving. If you’re looking for a job where there are clear-cut
answers in a guidebook, well, maybe you should be an accountant or something.
Every case is like a puzzle that needs a unique solution, and a lot of times, even
the best solutions need troubleshooting.
And a big part of learning how to solve these problems is looking at patients
holistically. You know what I mean by holistically, right? That means you have to
look at the whole situation and understand how all the parts of the situation fit
together. You have to look at the whole picture–health history, psychological
factors, family situation, financial situation, ethnic and religious factors. There are
all kinds of barriers to care you can miss if you don’t look at how the factors fit
together.
What are some of the biggest mistakes case managers make?
I think different case managers tend to make different mistakes. Like I said, it’s
really important to understand patients holistically. When case managers focus
exclusively on medical issues to the exclusion of a patient’s family or social
situation, that’s a big miss. And another serious error that case managers can
make is exceeding their scope of practice. It’s very important not to overstep
boundaries and make decisions that belong to physicians or other members of the
team. And that’s an easy trap to fall into… like, for example, it can be very tempting
to make a decision about changing a patient’s medication or dosage without
consulting the primary physician. Maybe the physician is hard to reach that day,
and maybe it seems very obvious to the case manager that a medication needs to
be discontinued. But those kinds of decisions can lead to critical errors and liability
issues. Case managers absolutely need to respect the primary physician’s role as
the team lead. And sometimes, like it or not, they need to follow orders.
In your experience, how has care coordination changed?
We’re starting to understand care coordination as a specialized job duty in a way
that we didn’t before. There’s always been care coordination. Nurses did that as a
part of their jobs, and they still do. But now we have full time case managers, and
schools are offering coursework and formal training in care coordination.
What are the some of the most important trends in care coordination?
Well, the health care system as a whole has gone through some major paradigm
shifts. From the perspective of our work, I think the most important trend has to do
with value-based payments. The hospital’s ability to receive reimbursement is
directly tied to quality and patient outcomes–especially since we’re an Accountable
Care Organization. Because of this, care coordination professionals play a crucial
role in overseeing care to prevent errors. And overall, this is a positive change that
improves patient care. But it does add a new level of pressure on case managers.
MSN6610 – The Nurse’s Role in Care Coordination: Activity Log
Samantha Rockwell
Social Worker
Can you please describe your role in the department?
I consult with case managers to make sure that they’re considering all the social
issues that impact a patient’s ability to get the care they need and to manage their
care. I meet with patients and find out what’s going on in their lives… their financial
situations, their family situations, possible barriers to care, anything really that
might impact their ability to get care. I also work with case managers to help locate
appropriate resources for clients.
In your opinion, what are some of the most important things a case manager needs
to know?
Case managers need to remember that care coordination is a transdisciplinary
field. You have to be able to collaborate effectively with an interdisciplinary team. In
fact, I would say that collaboration is possibly the most important skill that a case
manager needs. You work with all kinds of people both inside and outside the
hospital, and with insurance companies and families too. Nobody expects case
managers to have all the answers, but they need to know who to work with and
how to work with people to get these answers.
What are some of the biggest mistakes case manager make?
When case managers overlook barriers to care, that’s a big problem. Sometimes
case managers have blind spots when it comes to identifying these barriers. A few
years ago, I worked with a case manager that just didn’t seem to understand
transportation barriers. She would set up follow up care for patients way out in the
suburbs. But a lot of our patients, they rely on public transit and can’t get out that
far. Or they’re old and they don’t drive, or they don’t feel comfortable driving on
freeways to new places. I don’t know why it never occurred to her that this could be
a problem.
In your experience, how has care coordination changed?
There’s a lot more awareness of the importance of looking at patients’ needs as
they relate to sociological issues. This kind of awareness has been around
informally for a long time–I mean, nurses have always been aware of these kinds
of issues, and social workers have been employed by hospitals for a long time. But
now social workers are being brought in more routinely to assess situations, as
opposed to bringing us in later after something goes wrong. There are a lot of
opportunities for social workers to go into care coordination right now, and that’s
exciting.
What are the some of the most important trends in care coordination?
Thanks to the Affordable Care Act, most people have access to medical care now.
We used to see a lot of uninsured patients in the hospital, and now uninsured
patients are the exception. This is a good change, of course–a very good change.
But it also brings challenges. We’re working with people now who have little or no
experience with the health care system. They need to be educated on how to work
effectively with us. A lot of people don’t realize how things like deductibles work,
and that health insurance doesn’t cover every single expense. And the Affordable
Care Act also has led to more people in the system from lower socioeconomic
groups. These people tend to have more barriers to care. We have to anticipate
that some people will need more guidance through the system than others.
Patient Meeting
Panel participants
Samantha Rockwell
Social Worker
Lucas Branch
Diabetes Educator
Vicki Vasquez
Director of Case Management
Seth Patterson
Case Manager
MSN6610 – The Nurse’s Role in Care Coordination: Activity Log
Panel Q & A
Let’s hear what your new colleagues have to say about this patient.
Vicki: So, Seth, you were the case coordinator who was working with Mr. Decker and his
family. Can you tell me what happened?
Seth: Well, as you know, Mr. Decker came in with a badly infected toe. He was diagnosed
with diabetes last year. It sounds like he hasn’t been treating it effectively.
Vicki: Why do you say that?
Lucas: I spoke with Mr. Decker and his wife. It sounds like he’s been forgetting to take his
insulin. He said that’s only happened twice, but I got the sense from his wife that it
happens fairly often. Plus they both told me his diet hasn’t changed much since the
diagnosis. He’s lost about 10 pounds, which is great. But he’s still in the obese range.
Vicki: That’s too bad. Was the diabetes related to the toe infection?
Seth: It was probably a factor. He cut his toe while walking his dog. His wife washed the
cut and put a bandage on it. But it got worse. A nephew finally took him to his primary
physician, since he and his wife don’t drive on freeways anymore. The physician sent Mr.
Decker to the hospital.
Vicki: So explain to me what happened when Mr. Decker came here the first time.
Seth: Mr. Decker was given antibiotics and the infection started to clear up after a two-day
stay. Medicare wanted to send him home with antibiotics. We weren’t aware that his toe
wound had progressed and he had developed a more resistant infection.
Vicki: That’s too bad. Samantha, what was your involvement in this case?
Samantha: I met with Mr. and Mrs. Decker. I was definitely concerned that Mr. Decker
wouldn’t take the antibiotics if we sent him home. He also needed to treat the infection site
twice a day. Mrs. Decker assured us that us that she would take care of her husband and
make sure the infection was treated. But I was leery because it doesn’t sound like the
diabetes or the original cut was treated very well.
Vicki: So why was he sent home?
Seth: Well, for one thing, we talked to the Deckers’ nephew–the one who drove him to the
doctor and the hospital. He said that his wife was a stay-at-home mom and that she could
stop by twice a day to take care of Mr. Decker. Apparently this couple lives in the same
neighborhood as the Deckers. Also, the Deckers’ daughter was planning to fly in from
California later that week to take care of him.
Vicki: Did that happen?
Seth: No. Apparently there was a last-minute emergency at the daughter’s workplace, so
she wasn’t able to come. And it’s unclear to me how often the nephew and his wife
stopped by.
Samantha: Yeah. I spoke with the nephew. Apparently his wife wasn’t happy about being
volunteered for this situation. It sounds like she only stopped by a few times.
Vicki: So now Mr. Decker is back. It sounds like he is responding well to the new round of
antibiotics.
Seth: Thankfully, yes. At first we thought an amputation might be necessary. But he’s
doing remarkably well. He might be able to go home next week–except that we know
that’s not a realistic option.
Vicki: So what’s next?
Samantha: The Deckers don’t have the resources to pay for much that Medicare won’t
cover. A rehabilitation center might be a good option, but it will be a challenge to find one
they can afford. Other options would be home health care or an outpatient infusion center.
Vicki: Seth and Samantha, what are your thoughts about the outpatient infusion center?
Seth: At this point, I think that’s the best option. Mr. Decker doesn’t need rehabilitation. He
just needs someone to administer the antibiotics.
MSN6610 – The Nurse’s Role in Care Coordination: Activity Log
Samantha: I actually think a skilled nursing facility might be the better option. We’ve seen
that the Deckers aren’t able to handle this themselves, and that they don’t have a good
enough support system to help. The infusion center would only help with the antibiotics.
We need to make sure the infection site is cared for and that he gets some help with his
diabetes as well.
Seth: But that’s an expensive option they may not be able to afford–and I don’t think that
level of care is necessary.
Samantha: But I just can’t picture sending Mr. Decker home yet. I’m afraid he’ll wind up
back here again–or worse.
Patient Meeting Debrief
Denise McGladrey
Preceptor
Send him to a rehabilitation facility.
That’s certainly one option. But what if the Deckers can’t afford it?
Research options. Look for a rehabilitation facility that they can afford.
I would definitely do this. It sounds like Mr. Decker might not do so well at home
yet. Make some phone calls. However, be prepared for the possibility that they
won’t be able to afford a rehabilitation facility. You’ll need to consider other options
as well–like an outpatient infusion center.
Yes. There was reason to believe that Mr. Decker had enough help–his daughter
was coming, and his nephew said they would help.
You may be right. Should Seth have done more to make sure that Mr. Decker had
enough care at home?
Seth should have investigated the situation further.
I agree. He could have contacted Mr. Decker’s daughter and his nephew’s wife.
Those were the two people who were supposed to provide assistance, but Seth
didn’t speak to them personally.
Session Notes
You did not enter any notes for this session.
Session 3
Characters selected to interview
Seth Patterson
Case Manager
Lucas Branch
Diabetes Educator
Vicki Vasquez
Director of Case Management
Samantha Rockwell
Social Worker
Orientation Interviews
Seth Patterson
Case Manager
MSN6610 – The Nurse’s Role in Care Coordination: Activity Log
Can you please describe your role in the department?
I coordinate care for all kinds of people in the hospital. They tend to give me cases
involving older adults, since that’s my background, but for the most part all the case
managers need to be equipped to work with all kinds of cases. I worked with
geriatric patients almost exclusively with another hospital. Other case managers
come to me sometimes when they need geriatric resources or have questions
about how to help elderly patients.
In your opinion, what are some of the most important things a new case manager
needs to know?
Here’s a tip: make yourself a master list of phone numbers! I can help you get
started with that. After a while, you figure out who to call at each insurance
company when you really need to get something done, or who to call at various
social service agencies to get accurate information about resources, and so forth. I
can’t even tell you how much time my list saves me!
What are the some of the most important trends in care coordination?
Electronic medical records are revolutionizing what we do. And overall this is a
good thing. I mean, a big part of what we do is to try to prevent fragmentation of
care, and EMRs make a world of difference with that. On the other hand, as
someone who’s worked with elderly people, I know what a problem EMRs can pose
to patients who aren’t technologically literate. I’ve heard and seen horror stories.
One of the nurses at a clinic where I used to work, she told me about this elderly
woman who had elevated blood sugar levels. Her manager wouldn’t let her call the
woman to get a retest because the clinic wanted to push people into using the new
patient portal. You know, because of meaningful use issues? If enough people
didn’t use the portal, the clinic could lose funding. Well, this woman was in her 80s,
and lo and behold, she never looked at her electronic record and wound up at the
hospital with a blood sugar level over 600!
In your experience, how has care coordination changed?
Dealing with insurance companies and Medicare and federal regulations and all of
that… it just gets more complicated all the time. I like to think that I’m an advocate
for our patients, helping them navigate through all this red tape and regulation. If
it’s this hard for me to navigate things, I can only imagine how hard it is for the
patients–especially if they’re elderly or have language barriers and stuff like that.
What are some of the biggest mistakes case managers make?
One of the biggest problems case managers have is with coordinating transfers
from one facility to another–especially when you’re talking about older adults,
because moving them can be very risky. When patients go to the wrong facilities,
that can be traumatic for the patient and costly for the hospital. It’s important to do
your research and find the best possible facilities for patients so they don’t have to
be moved again. That can be a real challenge because of insurance issues… ugh!
It’s incredibly frustrating when the best facility for someone isn’t covered by
insurance. But that’s just part of our jobs…. negotiating stuff like that with insurance
companies on behalf of our patients’ best interests. It’s also really important to
figure out whether sending somebody home is a good idea. Sometimes home
health care is the best solution, but sometimes it’s not, depending on the family
situation and all kinds of factors you need to consider.
Lucas Branch
Diabetes Educator
What are the some of the most important trends in care coordination?
The team mentality has made a really big difference. The idea that you bring in a
diabetes educator, you bring in a dietician, you coordinate with a social worker….
that kind of interdisciplinary thinking leads to much better outcomes.
In your experience, how has care coordination changed?
That’s a better question for someone like Nora, who’s been working in this field for
so much longer than me! But even in the short time I’ve been here, I can see how
much more care goes into managing patient transfers. We do a lot more
investigating now to make sure patients are going to the right facilities.
What are some of the biggest mistakes case managers make?
As a team, it’s so important to do everything we can to prevent fragmentation of
care. Fragmentation brings costs up and quality down, and it can be really
dangerous. We need to make sure patients aren’t getting conflicting information or
medication from different providers.
In your opinion, what are some of the most important things a new case manager
needs to know?
From my perspective, case managers need to be aware that it’s critical to provide
patients with accurate information–and explain to them how to use it. With
diabetes, there’s so much misinformation out there. Some patients underestimate
the danger of diabetes and think it’s no big deal. Others are completely terrified and
think it’s a death sentence, and they don’t realize they have the power to manage
- And that’s true of other medical conditions as well. People rely way too much on
Dr. Internet to get the information they need. A case manager needs to make sure
that patients have real information they can use.
Can you please describe your role in the department?
I work with case managers to make sure that patients get the information they need
about diabetes care and prevention. When appropriate, I provide patients with
resources to help them manage their diabetes. Often I help patients who are
diagnosed with a chronic condition and who also have diabetes, since that new
condition might mean they have to make changes in their diabetes management
plan. I also talk with patients who have prediabetes or risk factors.
Vicki Vasquez
Director of Case Management
What are the some of the most important trends in care coordination?
Well, the health care system as a whole has gone through some major paradigm
shifts. From the perspective of our work, I think the most important trend has to do
with value-based payments. The hospital’s ability to receive reimbursement is
directly tied to quality and patient outcomes–especially since we’re an Accountable
Care Organization. Because of this, care coordination professionals play a crucial
role in overseeing care to prevent errors. And overall, this is a positive change that
improves patient care. But it does add a new level of pressure on case managers.
In your experience, how has care coordination changed?
We’re starting to understand care coordination as a specialized job duty in a way
that we didn’t before. There’s always been care coordination. Nurses did that as a
part of their jobs, and they still do. But now we have full time case managers, and
schools are offering coursework and formal training in care coordination.
What are some of the biggest mistakes case managers make?
I think different case managers tend to make different mistakes. Like I said, it’s
really important to understand patients holistically. When case managers focus
exclusively on medical issues to the exclusion of a patient’s family or social
situation, that’s a big miss. And another serious error that case managers can
make is exceeding their scope of practice. It’s very important not to overstep
boundaries and make decisions that belong to physicians or other members of the
team. And that’s an easy trap to fall into… like, for example, it can be very tempting
to make a decision about changing a patient’s medication or dosage without
consulting the primary physician. Maybe the physician is hard to reach that day,
and maybe it seems very obvious to the case manager that a medication needs to
be discontinued. But those kinds of decisions can lead to critical errors and liability
issues. Case managers absolutely need to respect the primary physician’s role as
the team lead. And sometimes, like it or not, they need to follow orders.
In your opinion, what are some of the most important things a new case manager
needs to know?
MSN6610 – The Nurse’s Role in Care Coordination: Activity Log
There’s a lot you need to know to be an effective case manager. One of the most
crucial skills is problem solving. If you’re looking for a job where there are clear-cut
answers in a guidebook, well, maybe you should be an accountant or something.
Every case is like a puzzle that needs a unique solution, and a lot of times, even
the best solutions need troubleshooting.
And a big part of learning how to solve these problems is looking at patients
holistically. You know what I mean by holistically, right? That means you have to
look at the whole situation and understand how all the parts of the situation fit
together. You have to look at the whole picture–health history, psychological
factors, family situation, financial situation, ethnic and religious factors. There are
all kinds of barriers to care you can miss if you don’t look at how the factors fit
together.
Can you please describe your role in the department?
Well, the part of my job that I like the most is serving as a role model and mentor to
the team members in this department. I’ve worked in care coordination for a long
time. So if someone feels like they’re up against a brick wall and can’t figure out
how to help a patient, I can put on my coach hat. I enjoy that. A more challenging
part of my job is working with the bureaucracy to make sure that patients get what
they need and that the hospital gets paid. Health care law and regulations change
all the time. You’ll be shocked at how much they change. As the leader of this
department I have to make sure I’m 100% on top of these changes–especially
since St. Anthony is an Accountable Care Organization. The hospital is constantly
evaluated on 33 quality indicators, and our ability to manage complicated cases is
essential if we’re going to keep our rank up.
Samantha Rockwell
Social Worker
What are the some of the most important trends in care coordination?
Thanks to the Affordable Care Act, most people have access to medical care now.
We used to see a lot of uninsured patients in the hospital, and now uninsured
patients are the exception. This is a good change, of course–a very good change.
But it also brings challenges. We’re working with people now who have little or no
experience with the health care system. They need to be educated on how to work
effectively with us. A lot of people don’t realize how things like deductibles work,
and that health insurance doesn’t cover every single expense. And the Affordable
Care Act also has led to more people in the system from lower socioeconomic
groups. These people tend to have more barriers to care. We have to anticipate
that some people will need more guidance through the system than others.
In your experience, how has care coordination changed?
There’s a lot more awareness of the importance of looking at patients’ needs as
they relate to sociological issues. This kind of awareness has been around
informally for a long time–I mean, nurses have always been aware of these kinds
of issues, and social workers have been employed by hospitals for a long time. But
now social workers are being brought in more routinely to assess situations, as
opposed to bringing us in later after something goes wrong. There are a lot of
opportunities for social workers to go into care coordination right now, and that’s
exciting.
MSN6610 – The Nurse’s Role in Care Coordination: Activity Log
What are some of the biggest mistakes case manager make?
When case managers overlook barriers to care, that’s a big problem. Sometimes
case managers have blind spots when it comes to identifying these barriers. A few
years ago, I worked with a case manager that just didn’t seem to understand
transportation barriers. She would set up follow up care for patients way out in the
suburbs. But a lot of our patients, they rely on public transit and can’t get out that
far. Or they’re old and they don’t drive, or they don’t feel comfortable driving on
freeways to new places. I don’t know why it never occurred to her that this could be
a problem.
In your opinion, what are some of the most important things a case manager needs
to know?
Case managers need to remember that care coordination is a transdisciplinary
field. You have to be able to collaborate effectively with an team. In
fact, I would say that collaboration is possibly the most important skill that a case
manager needs. You work with all kinds of people both inside and outside the
hospital, and with insurance companies and families too. Nobody expects case
managers to have all the answers, but they need to know who to work with and
how to work with people to get these answers.
Can you please describe your role in the department?
I consult with case managers to make sure that they’re considering all the social
issues that impact a patient’s ability to get the care they need and to manage their
care. I meet with patients and find out what’s going on in their lives… their financial
situations, their family situations, possible barriers to care, anything really that
might impact their ability to get care. I also work with case managers to help locate
appropriate resources for clients.
Patient Meeting
Panel participants
Samantha Rockwell
Social Worker
Lucas Branch
Diabetes Educator
Vicki Vasquez
Director of Case Management
Seth Patterson
Case Manager
Panel Q & A
Let’s hear what your new colleagues have to say about this patient.
Vicki: So, Seth, you were the case coordinator who was working with Mr. Decker and his
family. Can you tell me what happened?
Seth: Well, as you know, Mr. Decker came in with a badly infected toe. He was diagnosed
with diabetes last year. It sounds like he hasn’t been treating it effectively.
Vicki: Why do you say that?
Lucas: I spoke with Mr. Decker and his wife. It sounds like he’s been forgetting to take his insulin. He said that’s only happened twice, but I got the sense from his wife that it happens fairly often. Plus they both told me his diet hasn’t changed much since the diagnosis. He’s lost about 10 pounds, which is great. But he’s still in the obese range.
Vicki: That’s too bad. Was the diabetes related to the toe infection?
Seth: It was probably a factor. He cut his toe while walking his dog. His wife washed the cut and put a bandage on it. But it got worse. A nephew finally took him to his primary physician, since he and his wife don’t drive on freeways anymore. The physician sent Mr. Decker to the hospital.
Vicki: So explain to me what happened when Mr. Decker came here the first time.
Seth: Mr. Decker was given antibiotics and the infection started to clear up after a two-day
stay. Medicare wanted to send him home with antibiotics. We weren’t aware that his toe wound had progressed and he had developed a more resistant infection.
Vicki: That’s too bad. Samantha, what was your involvement in this case?
Samantha: I met with Mr. and Mrs. Decker. I was definitely concerned that Mr. Decker wouldn’t take the antibiotics if we sent him home. He also needed to treat the infection site twice a day. Mrs. Decker assured us that us that she would take care of her husband and make sure the infection was treated. But I was leery because it doesn’t sound like the diabetes or the original cut was treated very well.
Vicki: So why was he sent home?
Seth: Well, for one thing, we talked to the Deckers’ nephew–the one who drove him to the doctor and the hospital. He said that his wife was a stay-at-home mom and that she could stop by twice a day to take care of Mr. Decker. Apparently this couple lives in the same neighborhood as the Deckers. Also, the Deckers’ daughter was planning to fly in from California later that week to take care of him.
Vicki: Did that happen?
Seth: No. Apparently there was a last-minute emergency at the daughter’s workplace, so she wasn’t able to come. And it’s unclear to me how often the nephew and his wife stopped by.
Samantha: Yeah. I spoke with the nephew. Apparently his wife wasn’t happy about being volunteered for this situation. It sounds like she only stopped by a few times.
Vicki: So now Mr. Decker is back. It sounds like he is responding well to the new round of antibiotics.
Seth: Thankfully, yes. At first we thought an amputation might be necessary. But he’s doing remarkably well. He might be able to go home next week–except that we know that’s not a realistic option.
Vicki: So what’s next?
Samantha: The Deckers don’t have the resources to pay for much that Medicare won’t
cover. A rehabilitation center might be a good option, but it will be a challenge to find one they can afford. Other options would be home health care or an outpatient infusion center.
Vicki: Seth and Samantha, what are your thoughts about the outpatient infusion center?
Seth: At this point, I think that’s the best option. Mr. Decker doesn’t need rehabilitation. He just needs someone to administer the antibiotics.
Samantha: I actually think a skilled nursing facility might be the better option. We’ve seen that the Deckers aren’t able to handle this themselves, and that they don’t have a good enough support system to help. The infusion center would only help with the antibiotics.
We need to make sure the infection site is cared for and that he gets some help with his diabetes as well.
Seth: But that’s an expensive option they may not be able to afford–and I don’t think that level of care is necessary.
Samantha: But I just can’t picture sending Mr. Decker home yet. I’m afraid he’ll wind up back here again–or worse.
MSN6610 – The Nurse’s Role in Care Coordination: Activity Log
Patient Meeting Debrief
Denise McGladrey
Preceptor
Arrange for treatment at an outpatient infusion center.
That’s certainly one option. Let’s assume the outpatient infusion center is covered by Medicare. Do you have all the information you need to know before recommending this option?
There’s an important question that nobody asked.
That’s right. I agree that the outpatient infusion center is probably a good choice.
But nobody asked about transportation. Remember–the Deckers aren’t driving much anymore, and it doesn’t sound like they have a reliable neighbor or relative to take them. Before recommending this option, you should research medical transport companies to find out if this is a good option for getting Mr. Decker to his appointments. Or find out if there’s a facility close to their home that Mrs. Decker feels comfortable driving to.
Also, I wouldn’t give up on the rehabilitation facility idea. Call around and see if you can find a facility Mr. Decker can afford. Sending him home right now might now be the best idea if there’s an affordable alternative.
Yes. There was reason to believe that Mr. Decker had enough help–his daughter was coming, and his nephew said they would help.
You may be right. Should Seth have done more to make sure that Mr. Decker had enough care at home?
Seth should have investigated the situation further.
I agree. He could have contacted Mr. Decker’s daughter and his nephew’s wife.
Those were the two people who were supposed to provide assistance, but Seth didn’t speak to them personally.
Session Notes
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