Core competencies for a registered nurse (RN) are different than those for an RN care manager, says Mary M. Morin, RN, NEA-BC, RN-BC, vice president, nurse executive with Sentara Medical Group. When Sentara officially converted to a hybrid embedded case management model, RN care managers' job descriptions had to be rewritten; to be successful in this new model, they didn't necessarily have to have care management experience; instead, having a strong clinical background and experience doing patient assessments were more important.
To get RN care management away from the embedded telephonic model, we had to rewrite the job descriptions, and if you're going to rewrite job descriptions, have a new position. This is different work.
We found people will hear it, but until they go through it, until they feel it, they're all for it until it actually happens. If I were to do this again, I would make everybody reapply for their job because this requires a certain type of individual. These people need to be able to engage patients for a long-term relationship. They have to know how to work with hospital-based caregivers, home health, life care and not just within our own healthcare system.
We established core competencies. Core competencies for an RN care manager are different than those for an RN. We have an ambulatory-based RN. We were looking for people that didn't necessarily have previous care management experience, but who had experience doing patient assessments. They also had to have a strong clinical background.
Following are 10 more core competencies for the hybrid embedded RN care manager identified by Ms. Morin:
- Job descriptions: BSN requirement;
- Maintain patient lists by populations;
- Accept assignments;
- Meet expectations;
- Send patient letter from primary care physician (PCP);
- Engage patients;
- Send contact letter, brochure;
- Standardize work flow;
- Use SMG, Optima (Health Plan), and clinically integrated network (CIN) electronic medical record (EMR);
- Hold meetings with home health and inpatient care coordinators;
- Complete education/training; and
- Achieve specialty certification.
Hybrid Embedded Case Management: New Model for Cross-Continuum Care Coordination documents Sentara's successful hybrid approach to case management that has improved outcomes for both patients and physician practices.
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In this 25-page resource, Ms. Morin details the care management overhaul that has dramatically reduced ER utilization, hospital admissions and readmissions among high-risk 'VIPs.' Ms. Morin provides the following details:
and much more.
The 10 goals of Sentara's ambitious care management program that includes advance care planning and a strict seven-day follow-up metric;
- Its seven-pronged population health management model;
Composition and responsibilities of the care team, which includes providers, RN care managers, PharmDs and newly added social workers;
- Nuts and bolts of the SMG RN Care Management model, including patient assignments, core competencies, work flows, communication, education and training, and more;
- Addressing the behavioral and community health needs of vulnerable, high-risk VIPs;
- The challenges of engaging providers, staff and patients in this bold new case management approach;
- The nine key roles of the RN case manager, including care plan development, care transition management and advance care planning;
- SMG care management outcomes, including metrics on hospital admissions, readmissions, ED utilization and seven-day follow-up;
Lessons learned from program development and roll-out;
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P.S. -- You may also be interested in these embedded case management resources: