Create a winning team with care managers
Every role is important
An Iowa home care education manager recalls a recent case of a patient who was discovered wandering around the Dubuque area, scantily dressed, during the wintertime.
The agency’s psychiatric nurse was working hard to get the patient into a nursing home. But what the nurse didn’t know was that the agency’s social worker was advocating for the patient and doing everything she could to keep the patient in the home.
"They were working against each other," says Cindy Callahan, BSN, RN, staff development/ quality improvement manager for Amicare Home Healthcare of Dubuque, IA. The agency, which serves southwestern Wisconsin, northwestern Illinois, and central Iowa, is affiliated with Mercy Health Center in Dubuque.
That scenario would never have taken place if the agency had assigned a care manager to the case, Callahan says.
"In this case, the care manager’ should have been working to have both sides work together," she adds.
Callahan says she uses the term care manager instead of a case manager because the words "case manager" often conjure up images of someone at an insurance company who is deciding what types of therapies will be approved.
Callahan held an inservice about the care manager’s role. She wanted to change the way nurses saw their jobs. "What I saw was nurses were focusing so much on the nursing that they didn’t always see their role as the manager."
She compared the care manager to a football quarterback, who coordinates the team’s strategy. "I said, Imagine what a football team would be without a quarterback and how it would be chaotic,’" Callahan recalls.
Someone has to take charge, and typically, the primary nurse can be the care manager.
The care manager’s role is to look at the team’s game plan for both the short-term and the long-term goals.
"Before you play a football game you have to have a game plan, do some planning ahead of time, and I compared that to nursing and how you have to have a care plan," Callahan says. "You don’t just charge in there and fly by the seat of your pants."
At first, she held the inservice only for the team leaders and nurses, Callahan says. "But after we held it, the feedback I got was that I should be giving this to all of the other disciplines so they could understand what the care manager’s role was and what their role was."
Callahan explains these key points about a care manager approach to home care:
• Communication: Each home care agency has multiple disciplines doing patient assessments. "It’s real important for a care manager to look over those assessments and make sure there isn’t information that needs to be communicated to everyone," she says.
An example might be if a speech therapist visits a patient and notices some cognitive or perceptual problems. Everyone else might think the patient is fine mentally, but the speech therapist can tell that the patient is covering his deficits very well, Callahan explains.
"The patient acts like he’s getting it, but he’s really not," she says. "So if the speech therapist went in there and made this assessment, but no one passes this along to the rest of the team, then they’ll continue to visit the patient and believe the patient is understanding the education when he really is not."
One therapist may be better than two
Both the speech therapist and the care manager should notify, in writing, the other members of the team.
Callahan once attended an interdisciplinary conference and heard an occupational therapist discuss the exercises being done on a patient’s arm. "And the physical therapist said, I didn’t know you were in there because I’m doing these exercises.’"
So two therapists were giving the patient the same exercises, duplicating services, and adding cost to the patient’s care.
Again, communication would have prevented that from happening, Callahan says.
"If the physical therapist is doing what the occupational therapist is doing, then maybe we need to see if the physical therapist could do the whole thing," she notes.
The goal of communication is to get everyone on the team to work daily toward the same goals. And communication doesn’t have to mean formal meetings. It also could include case conferences or even stopping a care team member in the hall to update him or her on the patient’s progress.
• Coordination: "The thing I really stress is that the coordination of service really begins with communication because if you don’t communicate, you can’t coordinate," Callahan says.
Coordination of care starts with the referral and admission process, and it continues through the patient’s discharge.
Get it in writing
Documentation is the key to demonstrating coordination. "It’s OK to have a hallway conference; just jot a quick note down on the chart," she adds.
Amicare Home Healthcare requires a record review in the chart audit with criteria that there is documentation of coordination for all disciplines. The agency has its own quarterly report tool.
"We make sure we audit at least one chart for each nurse each quarter," Callahan says. This provides an up-to-date report on how the nurse is doing, and this is used as an education tool.
The team leader, who supervises the care managers, meets with each nurse once a week or every two weeks. The report is used to show whether the nurse is effectively communicating with therapists and other team members.
All of Amicare’s nurses are responsible for their own assigned caseloads, including obtaining physician’s orders. But the team leader is responsible for mentoring them.
• Teamwork: Teamwork is the general theme of care management. Each team may consist of a team leader, nurses, home health aides, a social worker, an occupational therapist, a physical therapist, and a speech therapist.
The team leader would be a nurse who has a great deal of home care experience, and the care manager would be a field nurse. A team approach will force staff to look at the big picture, instead of focusing narrowly on their own disciplines.
"Sometimes nurses have tunnel vision, and while they might see that the patient needs wound care, they get so focused on that and totally miss how the patient hasn’t got money for medication and needs a social worker," Callahan says.
Also, a team gives voice to all home care employees, including aides. Callahan says the aides are an important part of the team because they observe more and hear more about the patient.
"Aides see patients totally undressed and can pick up on a lot of things the others can’t," she says. "The care manager has to listen to the home health aides because they have valuable information and input."
Through teamwork, the agency can avoid a crisis. Team members can identify potential problems before they start because everybody communicates what they know to the team. And care managers help to coordinate intervention strategies.
An example Callahan uses is the case of a manipulative patient. The patient might try to sway people against each other, saying things like "My nurse says you didn’t have to do this."
But the team can form a game plan to make sure everyone handles and approaches the patient in the same way.
"There has to be someone who looks at the whole picture and gets everyone together to agree that this is how we’re going to handle this patient."
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