MSN6610 – The Nurse’s Role in Care Coordination: Activity Log

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

1. 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

1. 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

1. 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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