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Who are Care Managers and why are they important?

Think of a care manager as the “quarterback” of a client’s care team. They act as a personal advocate for their client’s health andwell-being and are responsible for ensuring that all aspects of care are coordinated and medical transitions go as smoothly as possible. Studies have shown that when a care manager is involved in a patient’s care and transition home from the hospital, it correlates to improved patient outcomes, patient satisfaction and an overall medical cost savings. (RFJW) At the start of in-home care, an assessment is performed and the care manager writes up a care plan based on the medical and personal needs of the client.  The care plan is then used as a guide for all members of the team to follow and document any changes in the client’s health. In addition to creating a plan of care, care managers also provide other invaluable forms of support: transitional support, continuity of care, family and client education, and coordination of outside resources. All of these contribute to higher quality of care, better outcomes for the client, prevention of readmission rates to hospitals, and fewer life-threatening situations.

Transitional Support

Coming home from the hospital can be a difficult and sometimes scary process, especially for clients with complex medical issues. The patient and family can be overwhelmed with new tasks, such as caring for a newly, established feeding tube, medication management, or ensuring a wound is kept clean. Care managers can help with the adjustment from the 24/7 assistance provided at the hospital to the resumption of home life, as they can provide additional education and help the client acclimate to their new space. This particular function of a care manager can be an invaluable resource to social workers and rehab facility discharge planners, as their oversight can help prevent readmission rates.

Continuity of Care

In times of medical distress keeping a clear path of communication between physicians, family members, and caregivers is a challenge to manage. Moreover, advocating for personal desires and concerns in certain health care settings is no easy task. Care managers can attend doctor’s appointments, make a push for further testing when they see a gap in care (as they have first-hand insight into the client’s health), speak up for the client’s wishes and ensure that all entities are informed and communicated with clearly about the client’s health.

Education

Care managers play an important role in client and family education. A care manager is someone who can help you to make informed decisions about your healthcare.

Resource Coordination

Care managers can make recommendations to help with a variety of issues. Their network within the healthcare industry can be a wonderful resource for clients. From support groups and organizations to medical equipment suggestions, care managers can connect patients to tools that help make their life and family’s life easier and more fulfilling.

Does having a RN Care Manager really make a difference?

The benefit of having a nurse as your care manager really boils down to one main concept: medical expertise. Registered nurses have been trained to identify potential medical concerns that can directly impact the outcome of care.  Moreover, a nurse has been trained to see the signs of infection, reduce errors with medication, spot potential gaps in care, and can identify areas where the client or client’s family may benefit from additional resources. Moreover, most nurses have worked in a healthcare setting for some time and have experienced a wide range of medical scenarios. At CHCS, we have on-staff nurses who provide care management to our clients. Often the RN care manager knows the questions to ask to identify and prevent potential emergent symptoms and situations. We asked our RN care managers for a few examples of times when they felt their expertise made a significant impact on the lives of their clients.

In one instance, one of our nurse care managers was taking a heart rate and noticed that it was irregular and fast paced. She asked the client to stand to monitor her postural vital signs. Upon standing, she noticed that the client’s heart rate shot up and her breath sounds decreased. An alarm bell sounded in her mind.  With her background, she knew that something was amiss. Her primary concern was atrial fibrillation. So, she asked if she could take a look at the client’s feet. Her feet showed pitting edema, which she recognized to be a sign of congestive heart failure. The nurse knew immediately that no one (caregivers, etc…) should have her get up and walk around or move her until she was evaluated by someone at an emergency department. At first, the client was reluctant to be seen by a physician, however with the nurse’s knowledge on the subject, she was able to coach the client and keep her calm through the process. The client was transferred to the hospital where she was diagnosed with congestive heart failure and atrial fibrillation and was admitted to the hospital and treated for her condition. In this case, having a care manager who was medically trained and had the foresight to make additional checks, was potentially life-saving.

Another example of how having a nurse as a care manager can make a difference is in regard to resource coordination for families. One such example involves an RN care manager who was listening to a client’s spouse talk about how tired she was from getting up in the middle of the night to help her spouse with toileting. The RN thought to probe a little further and ask her exactly what she meant. It turned out that the spouse was dealing with issues of nighttime incontinence and was changing bedding in the early hours of the morning. The RN was able to suggest the use of a condom catheter during the night and the spouse was able to get some much-needed rest.

As you can see, care management can be an invaluable resource to clients, their families, and the professionals who treat them. At CHCS, we hold improved client outcomes and quality of life as values. Providing excellent, care management is one way that we can ensure this happens.

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