In my early days of case management, I quickly realized that a daily work plan was essential. It also became apparent that in spite of that plan it would be necessary to be flexible. My organizational plan each day started with:
1) printing out a census of the clients in my care & level per criteria for inpatient status appropriateness.
2) a review of those clients including date and reason for admission, medical history, social history, labs, insurance coverage.
This information would be necessary to form a safe discharge plan for each individual. But that was just the start of the process.
Case management rounds with the multidisciplinary team of M.D.’s, Nursing staff, any Therapies and Social Workers were invaluable in the creation of an appropriate plan.
Consulting the Patients & Families
I would then meet and assess any new client to explain my role in their care. It was important to know the home status, with whom they lived, any current home services involved, determine a need for home care services, if there was family supports, safety issues, & ability to care for themselves. Ongoing clients would be reassessed for any changes.
The days expected discharges would be identified early (if we were lucky!) so discharge plans could be firmed up. Discharge planning begins upon a client’s admission to hospital. Referrals to short–term or long–term care, private home care, VNA services, acute rehab – per client choice, insurance coverage were made as soon as needs were identified.
Flexibility was needed for the frequent last–minute discharges. We were often told to “ work your magic “ by physicians requesting a change of plan such as a late in day discharge; or other nearly impossible discharges that really did require a lot of magic to pull together. Social workers had the difficult job of assisting those with no insurance, homeless, or without resources.
All and all however I really enjoyed my role as a case manager. Often it was a very complex and demanding role. What I found most rewarding about it was that it utilized all of a nurse’s skill and experience.
— Mary King, RN