A study conducted by the Commission for Case Manager Certification (CCMC) cites increasing demand for certified case managers. The CCMC’s 2014 Role and Function Study also found that employers are willing to pay higher salaries for professionals whose education, training, and certification demonstrates a higher level of knowledge, skills, and overall competency. Further, the study revealed that 40.2% of employers are now requiring their case managers to be certified. Contrast this figure to the 25.9% of employers requiring certification in 2004. The CCMC’s conclusion regarding a growing demand for well-trained and credentialed case managers is supported anecdotally by the actions of many health care organizations.
Clearly, case management presents a strong career path for nurses and even greater opportunities today. The opportunities can be even greater for minority nurses, including African Americans, Asians, Hispanics, Filipinos, and Native American and Alaskan nurses, for which there is already a concerted effort to recruit so that they can bring their cultural competencies to our nation’s increasingly diverse patient population. However, continuing education and training are musts for any nurse who truly wants to make a difference in his or her patients’ lives while also realizing his or her full professional potential and earning power. The education starts by understanding how the market is driving increasing demand for case managers and, the educational resources available to help them become key catalysts for the delivery of better health care in America.
Not Just a Personal Choice–Employers Demanding Higher Skills
While the Patient Protection and Affordable Care Act of 2010 (ACA) raised the bar on expected standards of care and paved the way for increased demand for case managers, market conditions were already driving the need up. The graying of America, coinciding with the increased incidence of chronically ill patients of various ages succumbing to diseases of the 20th and now 21st century (e.g., obesity, high blood pressure, and chronic pulmonary obstruction disease) all have placed greater demands on health care providers. This, in turn, prompted many to increase their hiring of case managers—also being called care coordinators, patient advocates, and a host of other titles. For example, back in 2012, the UCLA Health system in Los Angeles began hiring full-time care coordinators to work with doctors serving in its primary care clinics. By 2015, UCLA had 24 “Comprehensive Care Coordinators” serving in its ambulatory primary care clinics.
Other health care organizations across the country, including hospitals, accountable care organizations, managed care firms, and insurers were and are actively increasing their case management staff. Some examples are: Advocate Health Care, Bon Secours Health System, Banner Health, Mercy Health Select, Partners Healthcare and the University of Michigan Health System. Based on the CCMC’s figures, by 2015 there were 37,000 certified case managers serving in U.S. health care organizations versus 20,000 in 2010. An estimated 89% of the certified case managers are registered nurses. The balance is comprised of social workers (4.4%), vocational rehabilitation counselors (2.3%), and others.
Despite the growing demand for case managers, the profession is not without its challenges. Of the over 100,000 professionals involved in case management, their average age is estimated by various surveys to be 53 years old. The transfer of knowledge from these experienced professionals to their younger counterparts is essential as demand rises and many of the field’s most skilled are entering the retirement years. Through continuing education, training, and mentoring of newer case managers by experienced case managers, some of the deficits in skills and knowledge can be addressed.
The federal government is acutely aware of the importance of training for RN case managers. In fact, the government has established a fund of $20 million for training, specifically in the areas of data collection, reporting, and practice changes to help smaller health care practices improve. Many minority nurse case managers serve in smaller health care practices, in addition to large urban hospitals, so they may very well be beneficiaries of this federally-funded training. Employers too are hosting more educational and training programs for their case management staff and encouraging their personnel to participate in continuing education programs, not just for licensing compliance purposes, but for their own skill development and career advancement.
Based on current PayScale data, Certified Case Managers with the title of Nurse Case Manager are averaging annual salaries of between $60,514 to $89,132, depending on the employer and region of the country. Directors of Case Management are commanding average annual salaries within the range of $75,978 to $145,177, and those with the title of Registered Nurse, Utilization Management, are averaging annual $61,545 to $98,197.
Most RN case managers can aspire to become leaders in their departments, assuming they have earned their CCM designation and are committed to being continuous learners. Knowing the options in continuing education case management training programs and resources available and how to select wisely is tantamount to building best practices in case management and assuming leadership roles.
Continuing Education and Training Resources
StateCE, a part of Vista College, reported that nearly 76 million adults in the U.S. are enrolled in some form of continuing education. Many human capital development experts believe that training from outside continuing education providers offers a distinct advantage over in-house training programs. It is their contention that this education helps individuals gain a deeper level of knowledge—both theoretical and practical, as well as enhancing their problem-solving and collaboration skills. In addition to gaining higher-skilled employees, employers gain the added benefit of continuing education promoting staff retention. A study by Spherion Atlantic Enterprises reported that 61% of employees who receive continuing education remain with their current employers for at least five years.
Continuing education (CE) resources include independent organizations, colleges/universities, professional organizations, and internal training departments. Their offerings range from onsite CE-credit seminars and certification workshops, webinars, and various long distance e-learning programs. The best continuing education programs and resources for case management have certain traits in common. They are:
Developed and provided by credentialed professionals with both clinical and business experience;
Goal-oriented, whether the goals, for example, be: certification, gaining best practice skills, gaining knowledge about a specific medical condition and/or patient population, learning how to manage a case management department, or learning what it takes to start your own case management firm; and
Have specific learning objectives clearly conveyed regardless of whether the program or educational resource involves an instructor or self-learning.
Along with meeting these criteria, there are other specifics which seem to be important in the effectiveness of a continuing education program. For instance, data uncovered in 19 studies and discussed in a Nurse Education Today article titled “Review of continuing professional education in case management for nurses” found that the “most appropriate program length appears to be at least 16 hours.” Further, the findings were that a combination of interactive lectures and small group discussions were associated with the most positive learning outcomes. What we know is that each type of continuing education program or resource has a valuable role to play.
Different Benefits of Different Educational Formats
Following are some examples of different continuing educational offerings, their various formats, and the benefits they deliver:
Onsite Seminars. These seminars are presented by qualified instructors with both clinical and business experience and are ideal for engaging case managers, giving them a direct line to an experienced professional whose insights into processes and nuances are without a doubt vital to professional growth and advancement. These events also give case managers an opportunity to share their experiences with and learn from their peers. On that level, they help to boost morale, build professional camaraderie, and instill a sense of professional pride.
CCM Certification Workshop. This workshop has a specific purpose in helping a case manager prepare for their certification exam. These workshops, especially those backed by the CCMC, deliver education and up-to-date information about best practices in today’s case management, while also imparting need-to-know information regarding the eligibility requirements and application process for the gold-standard case management credential—the CCM®—and how to prepare for the exam.
Setting-Specific Educational Programs. Setting-specific programs, such as a Hospital Case Management Seminar, are customized for a specific hospital’s needs and designed to help a hospital case management staff achieve improvement across key quality metrics, as well as overall health care efficiency and cost-effectiveness. Because the program is hospital-specific, it also has the residual benefit of instilling in each participant a renewed passion for their role and commitment to their organization.
Agency-Specific Educational Programs. These programs are for case managers serving with the Veterans Administration system or Indian Health Services organizations; both of which encounter very unique challenges both from a patient and administrative perspective and thus require continuing education that recognizes and helps case managers function at their best within the constraints of these settings.
Patient Population, Medical Condition, or Challenge-Specific Educational Programs. These programs, such as those tackling pediatric case management, obesity, our nation’s multiculturalism, the aging population, or health literacy problems, delve deeply into a specific topic to give case managers a broader, more comprehensive understanding of a medical condition or challenge they are likely to be handling already.
Seminars on DVD. These offer the best of both worlds. Case managers can gain access to a great seminar, perhaps being conducted in a city too far from their location, by simply purchasing the seminar on DVD. This gives the case manager a virtual seminar experience right from the convenience of their own home or office. It also enables case management department supervisors to have a “refresher course” right at their fingertips for easy access to continuous learning, and to provide to new staff members. Many of the profession’s best seminars on DVD come with handouts, video clips, and some even offer a phone consultation with the program instructor.
Seminar e-Workbooks. These are also ideal for case managers who can’t attend a seminar but recognize the importance of their learning the information presented at the seminar. Often, these e-Workbooks are provided on convenient flash drives and include PowerPoint presentations, case studies, and other resource materials.
Textbooks and Related Home Study Programs. These are perhaps the perennial continuing education resource for case managers. Every case manager’s personal library and every health care organization’s training room should be equipped with the profession’s best textbooks. Today, some of the most prolific authors, whose textbooks are used by nursing schools worldwide, also offer companion home study programs to their books and associated continuing education tests approved for CE credits. For instance, The Case Manager’s Handbook Home Study Program offers a continuing education test, which has been approved for 80 CE Credits. It can be taken online to prepare for the CCM exam or to help case managers meet their CE credit requirements.
Learning Management Systems. These are another option for personal learning growth and career advancement. They are typically module-based to make for easy, convenient learning and are organized in a sequence that promotes the best building of knowledge and acquisition of skills.
Closing Remarks
Continuing education should not be viewed by case managers as a necessary evil for maintaining their professional license, but rather as a valuable tool worthy of their investment. Continuing education is essential for building knowledge and skills, helping case managers become better patient advocates and better employees able to support their employer’s quality of care, risk management, and fiscal objectives. Moreover, through continuing education accessed through a multitude of options, case managers can take control of their own careers and position themselves for optimum advancement opportunities, salary gains, and potential leadership roles. It is incumbent upon minority nurse case managers to recognize that the investment they make in their continuing education and continuous learning is a clear path to gain a greater voice in our nation’s health care system. Through continuing education and the greater opportunities, it affords, they are in a better position to raise awareness of the value of high-quality case management, and in turn, make a greater difference in the lives of all patients across all communities.
Shifting demographics and other market conditions have created a greater need for minority nurses, particularly in certain roles. With a growing multicultural and aging population in the United States, the need for medical case managers to serve patients of various ethnic and minority groups has significantly increased. Regulatory reform—specifically, the enactment of the Patient Protection and Affordable Care Act, which ushered in new preventable readmission requirements for hospitals, along with new models of care (e.g., patient-centered medical homes and physician-hospital organizations) and more prevalent consumer-driven health care plans—has created new opportunities for minority nurses in case management. For minority nurses whose goals are to help serve these largely underserved patient populations and advance in their careers, it is important to understand the changing health care landscape.
Let’s look first at our nation’s changing demographics. The graying of America has resulted in more Americans living longer with more age-related, chronic medical conditions, ranging from arthritis, hypertension, and heart disease to hearing impairments and cataracts. According to the National Academy on an Aging Society (NAAS), almost 100 million Americans have chronic conditions, with millions more developing chronic conditions as they age. By 2040, the NAAS estimates that the number of people in the United States with chronic conditions will increase by 50%. The cost of medical care for Americans with chronic conditions could approach $864 billion in 2040—almost double what it was in 1995. While the most common chronic conditions are the same for blacks and whites, the conditions are generally more serious among minority populations, particularly individuals with lower incomes.
Another major factor in our changing health care landscape is the higher percentage of racially and ethnically diverse individuals. An AARP Bulletin article titled “Where We Stand: New Realities in Aging” reported that minorities are expected to comprise 42% of the American population by 2030. Currently, the United States has 150 different ethnic cultures represented within its population, with over 300 different languages spoken and a wide range of cultural nuances reflected. For health care providers, this broad spectrum of cultural diversity in its patients introduces higher incidences of certain conditions, while also posing challenges relating to care and communications.
Addressing Cultural Challenges
On the disease front, we know that certain ethnic groups are more prone to certain medical conditions. Many health care providers and insurers are responding with targeted initiatives, such as: the Chinese Community Health Plan’s Diabetes Self Management: A Cultural Approach initiative to enhance diabetes knowledge and management in the Chinese population; Excellus Health Plan’s Healthy Beginnings Prenatal Care program to decrease NICU admission rates for African American teens; and Med One Medical Group’s Adherence to Hypertension Treatment and Measurement project to educate English, Arabic, and Vietnamese-speaking hypertensive patients.
Beyond the obvious language and communication barriers that can prevent quality health care delivery and optimum patient outcomes, there are cultural issues that, if mismanaged, can also interfere with providing quality health care. For example, in Latin culture, religious healing, praying to certain saints, and relying on religious symbols to address health issues are not uncommon. Patients of African descent are inclined to believe in the healing power of nature and their religion. Within Asian groups, achieving balance between yin and yang, using certain herbs and foods, and relying on acupuncture to unblock the free flow of energy (chi) are common practices. Health behaviors also vary among ethnic groups. Armenians are tolerant of county health facilities, whereas the Vietnamese regard them and the related bureaucracy associated with government facilities as degrading. They, therefore, prefer receiving care in a physicians’ office, even if higher costs are incurred.
There also are differences relating to how certain minority and ethnic groups want to hear about their medical conditions. Did you know that the majority of African Americans and European Americans believe patients should be informed of terminal illnesses, while fewer Mexican Americans and Korean Americans agree? Family values relating to health care decisions also differ among minority and ethnic groups. Within the Mexican, Filipino, Chinese, and Iranian cultures, for example, there is the belief that a patient’s family should be first informed about a loved one’s poor prognosis so they can decide whether or not the patient should be informed. Obviously, these variables and many others are important for health care professionals to understand when caring for a patient. This is an area where minority nurses of different backgrounds and cultures can be a tremendous asset to their patients and to the overall health care system. Studies have demonstrated that case managers help strengthen primary care. This is particularly true when patients have complex or multiple medical conditions—as many elderly people do—or chronic conditions such as diabetes or chronic obstructive pulmonary disease.
Combating Disparities in Health Care
It is widely known that disparities exist in the care of minority patients. While this is more pronounced in rural primary care practices, it holds true across the board. An Institute of Medicine report found that “racial and ethnic minorities tend to receive a lower quality of health care than non-minorities, even when access-related factors, such as insurance status and income, are controlled.” Other studies also have explored these disparities, including Aetna’s “Breast Health Ethnic Disparity Initiative and Research Study” and Health Alliance Plan’s “Addressing Disparities in Breast Cancer Screening.” Collectively, they further make the case for minority nurse case managers to advocate for minority patients.
Related research supports the fact that, where minority case managers are in place, there is a significant improvement in patient outcomes. This was evident in a study of rural African American patients with diabetes mellitus where it was found that they were able to better control their blood sugar levels with a redesigned care management model, which incorporated nurse-led case management and structured education visits into rural primary care practices.
From Public Sector to Hospitals, Physicians’ Offices, and Entrepreneurial Settings
There is no question that, given today’s health care landscape, minority nurses have a great opportunity to help make a difference in the care of minority groups and enjoy heightened career fulfillment and potential advancement. Among the settings minority nurses can consider are:
• The public sector—serving within the Veterans Health Administration system for our veterans, many of whom are minorities, or the Indian Health System for our nation’s native American populations;
• Hospitals—helping hospitals achieve lower rates of preventable hospital readmissions, caring for minority and ethnic patients, and serving as a patient advocate and liaison with family members;
• Physicians’ offices—facilitating patient-physician communications, assuring appropriate records are communicated between treating physicians, monitoring patients’ adherence to treatment plans, and identifying any family and/or home issues that might affect a patient’s well-being;
• Financial advisors and estate planning attorneys—working with these professionals who are becoming increasingly more involved in the financial aspects of their clients’ health care and the costs associated with their care, as well as protecting their clients’ estates;
• Independent practice—working for a case management firm or establishing your own practice.
Independent practices present an opportunity for minority nurses to shape their own destiny and financial reward. Through one’s own practice, a minority nurse can focus more fully on his or her patients’ well-being without the over-emphasis on cost containment we see in many other practice settings, especially hospitals. These nurses can decide that they want to specifically dedicate their practice to a certain minority and/or ethnic group. They can establish a truly patient-centered care management business model, performing health risk assessments, providing health coaching, disease education and management, assisting with patient transitions of care, coordinating health care resources on behalf of their patients, reviewing hospital bills, helping patients assemble their health records, and providing end-of-life care coordination.
Based on a 2013 survey by the National Council of State Boards of Nursing and The Forum of State Nursing Workforce Centers, nurses from minority backgrounds represent 17% of the registered nurse (RN) workforce. Currently, the RN population consists of 83% white/Caucasian, 6% African American, 6% Asian, 3% Hispanic/Latino, 1% American Indian/Alaska Native, 1% Native Hawaiian/Pacific Islander, and 1% other. Given the increasing shortage of nurses, combined with the growing demand based on our shifting demographics, it appears that the time has never been better for minority nurses, while fewer in number, to take center stage in case management.
Catherine M. Mullahy, RN, BS, CRRN, CCM, is president of Mullahy & Associates www.mullahyassociates.com, and author of The Case Manager’s Handbook, Fifth Edition.
When the man entered the hospital, his diabetes and his weight had spiraled so far out of control that his doctors feared he would not survive. Maria Ortiz, RN, CCM, a case manager for the insurance company Aetna’s North Central region, was assigned his case.
For an entire year, she helped coordinate his care and monitored his progress–from the hospital to a skilled nursing facility and finally back to his home. She spoke by phone so frequently with the man’s wife that they recognized each other’s voices from the first friendly hello. And although she never actually performed any of the patient’s hands-on care, Ortiz felt the joy of his recovery just as much as if she had been his bedside nurse.
Maria Ortiz, RN, CCM
Nurse case managers like Ortiz care for the most chronically and seriously ill and injured patients in the health care system. They work for a variety of employers, including hospitals, health insurance plans, HMOs, rehabilitation facilities, government agencies, workers compensation insurers and more. In addition, some nurse case managers strike out on their own as independent consultants, offering their services to patients’ families, insurance companies and health care providers.
Case managers assess, plan, coordinate and monitor services up and down the health care continuum to ensure that patients get the high-quality care they need in a prompt, cost-effective manner. The ultimate goals are a healthier population and more-affordable health care.
One of nurse case managers’ most critical functions is to educate patients, guiding them to follow dietary, exercise and medication recommendations. According to the American Heart Association, complications from patients’ failure to take prescribed medication as directed by doctors account for 125,000 deaths per year in the United States, a mortality rate exceeded only by heart disease, cancer and stroke.
No matter what setting they work in, the chief role of nurse case managers is that of patient advocate. Case managers who work for insurance companies, for instance, make sure members get the services to which they’re entitled under their benefit plans. They also help negotiate better rates for services that aren’t covered or help find community resources to fill the gaps. Yet many Americans continue to harbor the misconception that insurance company case managers are bean counters whose only concern is to save the company as much money as possible.
“I’ve never been asked to compromise a member’s care or well-being based on cost,” says Joyce Rogers-Granberry, RN, an African-American nurse who is a regional case management director for WellPoint Health Networks. “We focus on what’s going to bring the most value to the patient.”
Adds Ortiz, “Even though I work for the insurance company, I really work for the patients and do whatever is best for them. I’m the human being behind the insurance company.”
Culturally Competent Case Management
Case management is an advanced, specialty practice. Entry-level nurse case managers must be RNs, preferably with a bachelor’s degree in nursing, and have at least two years of nursing experience. That experience is essential because a case manager must have a working understanding of the health care system, according to the Case Management Society of America (CMSA), an 8,200-member professional association based in Little Rock, Arkansas.
Experience in utilization review and home health care is also helpful. In fact, some insurers require home health care experience because their nurse case managers coordinate care after the patients are discharged from hospitals or skilled nursing facilities.
According to a 2003 salary survey conducted by CMSA and ADVANCE for Providers of Post-Acute Care magazine, average annual earnings for case managers–including those in allied health or social service fields–range from $50,000 to $57,000, depending on location. Case managers in metropolitan areas earn the most, with a nationwide average salary of $53,833. The national average earnings for case managers in suburban areas and in rural areas are $50,000 and $49,666 respectively, the survey reports.
Best of all, demand for nurse case managers is fierce. “Employers tell us that finding qualified nurse case managers is one of the biggest challenges they’re facing right now,” explains Jeanne Boling, MSN, CRRN, CDMS, CCM, executive director of CMSA.
Most of the job opportunities are in managed care and hospital settings, Boling continues. Meanwhile, a growing number of nurse case managers are setting up their own practices.
Because cultural competency is a top priority in case management, there is a great need for more racial and ethnic minority nurses in this specialty. Bilingual nurses are in particular demand, especially in workers compensation, says Claudia Worth, RN, a principal of Compass Continuum, a nurse case manager staffing company serving the Denver metropolitan area. She is also a principal of RNCaseManager.com, an online resource for nurse case managers.
Ortiz agrees that there is a critical need for bilingual case managers who can translate information for patients who speak little or no English. Ethnic minority nurses also bring personal perspectives that enable them to coordinate care in a culturally sensitive way, she adds.
In some Hispanic cultures, for instance, doctors are viewed as supreme authorities, which makes patients reluctant to seek second opinions. Yet in other Hispanic cultures, doctors may be viewed with suspicion. Ortiz tells of one patient from the Dominican Republic whose beliefs in voodoo led him to distrust physicians. Understanding the nuances of different cultural subgroups helps nurse case managers communicate more sensitively with patients and their families, which can lead to better outcomes for the patients.
Never a Dull Moment
A nurse case manager’s job is never dull, and it requires strong organizational skills. Case managers carry average caseloads ranging from 22 in rehab facilities to 47 in managed care, medical group or workers compensation settings, according to CMSA and ADVANCE for Providers of Post-Acute Care. (Those figures, however, include caseloads for social workers and other types of case management professionals, not just nurse case managers.) Some case managers can even carry 60 or more cases at a time. New cases come in every day and case managers must prioritize.
Rogers-Granberry says a typical day for a case manager at WellPoint might begin with a phone call informing him or her that a health plan member has been in a serious car accident and suffered a spinal cord injury while on vacation. First, the case manager would coordinate getting the member to the closest hospital, where his condition could be stabilized. Then the case manager would coordinate his transfer to a hospital where he could be treated, all the while working closely with the member’s family and with doctors. If the patient needed a service that wasn’t covered by his health plan, such as an air ambulance, the case manager would work with service providers to negotiate the best rate possible. Once that crisis was under control, the case manager would take care of details of other cases that required attention that day.
In some instances, a patient can have more than one case manager–perhaps one working for a hospital and another working for his health insurance plan. The two case managers then work together to coordinate care. As Ortiz puts it, “We help them and they help us.”
As a case manager for mental health emergency services at Jackson Memorial Hospital in Miami, Ruby Murphy, RN, MS, juggles the cases of 20 to 25 patients who are already in the hospital, plus up to 40 patients who come into the emergency room each day. “You really have to start organizing your day in the car on your way here,” says Murphy, who is African American.
She communicates by phone, email, walkie-talkie or fax with nurses, doctors, social workers and other hospital staff, as well as family members and representatives of community agencies and insurance companies. She also does walking rounds to review charts and talk to hospital staff face-to-face when necessary. Her goal is to gather and share information as fast as possible so patients get the care they need.
Obviously, good communication skills are critical. Murphy says case managers must be able to establish rapport with a wide range of people–from hospital housekeeping staff to surgeons to insurance administrators.
In a mental health setting, case managers must have both general medical knowledge and psychiatric knowledge in order to assess patients, she adds. For example, sometimes it’s necessary to transfer a patient from the mental health unit to the general emergency department.
Case managers also must be resourceful, because they often have to find ways to fill the gaps in a patient’s care. That could mean helping patients get transportation to a pharmacy or helping them get enrolled in a government insurance plan, such as Medicaid.
Is Case Management Right for You?
Case management isn’t for everybody. The job involves working in an office, rather than at bedside, and the case manager’s primary tools are the computer, telephone and fax machine. This career also requires a broad perspective of the health care field.
“For some nurses, it’s very hard to make the transition to the managed care area,” says Lisa Harris, BSN, RN, CCM, a case management supervisor for WellPoint in Atlanta. “You have to look at the business aspects of health care in conjunction with the clinical side.”
This means case managers take into account considerations such as benefits, eligibility, contractual and legislative issues, as well as medical and clinical practices, in order to make medical necessity determinations. All of these components are critical for making sure patients are treated consistently according to the current standards of practice.
On the other hand, if you’re a long-time bedside nurse who feels it’s time to explore new career possibilities, case management may be just what you’re looking for.
After beginning her career in clinical nursing, Harris, who is African American, got the opportunity to work in a utilization management department at a peer review organization. She later transitioned into quality improvement and then into case management. She has worked in managed care on the hospital side as well as for a variety of national health plans. In her current supervisory role, she leads a comprehensive case management team and is the interim supervisor for the East Coast transplant case management team.
“I love to learn new things and seek out new challenges,” Harris declares. “Case management encompasses the best of both worlds. As a case manager, you assist members not only while they’re in the hospital or in the acute phase of their illness, but you also have the opportunity to follow their care through a continuum.”
She likes being part of the whole spectrum of care and getting the satisfaction of seeing plan members enjoy optimum results at the end of the process. She especially cherishes the notes and photos her team receives from grateful parents whose babies are thriving despite having been born prematurely. Harris can’t help but take delight in the photos of them now as toddlers, smiling and walking and bringing joy to their families.
Every case manager recalls special cases that touched their hearts. Murphy remembers the case of an elderly woman with dementia who got on the wrong bus and ended up in Miami, not knowing who or where she was. Murphy coordinated the search for the woman’s family and her care while she was at the hospital. After an APB was issued, the frantic family contacted the hospital from their home in New York and flew to Florida to pick her up. “They were very gracious and were just so happy to see their mom,” Murphy says.
Such happy endings are the great rewards of case management careers, she adds. “I find that assisting people at this level is just as vital as stopping the bleeding at the bedside.”
Ortiz became a case manager after working as a nurse for 30 years, first in general nursing at hospitals and then in home health care. She figured she wouldn’t have the physical stamina to do hands-on care for the rest of her career and she was ready for new challenges. She seized an opportunity to be a case manager at Aetna, and now, she says, “I don’t think I’ll ever go back to anything else.”
For More Information on Case Management Careers
The Case Management Society of America, www.cmsa.org, offers educational programs, an annual conference, interactive networking forums, leadership training, publications and an online career center with listings of current job openings and a resume database.
The Association of Rehabilitation Nurses, www.rehabnurse.org, has a case management Special Interest Group.
RNCaseManager.com provides job and resume postings, an online case manager forum, online continuing education courses and links to resources for case managers.
The International Association of Rehabilitation Professionals, www.rehabpro.org, has a case management section on its Web site.
What Makes a Good Case Manager?
According to the Case Management Society of America, these are some of the key skills and qualities necessary for a successful career as a case manager: • Problem solver • Catalyst • Negotiator • Communicator • Out-of-the-box thinker • Independent • Creative • Caring • Determined • Sense of humor
What is social capital and can social capital play a role in better asthma outcomes in children residing in homeless shelters? These were some of the questions that guided a research proposal for the Research Infrastructure in Minority Institutions—Career Opportunities in Research (RIMI-COR) grant at Mercy College. Funding for this study was made possible in part by a grant from the National Institute on Minority Health and Health Disparities.
A pilot study was undertaken from October 2008 through August 2009 to quantify if social capital structures existed in three homeless shelters in New York City and if shelter residents were aware of these structures, and to examine parental perceptions about their child’s asthma (controlled/uncontrolled and mild/moderate/severe) and clinician concordance of parental assessment.
Five Mercy College nursing students assisted the researcher in this study with literature reviews and data collection. Engaging nursing students in research is an important venue because it gives students opportunities to examine health issues that are outside of their purview. Further, the students participating in data collection learned about social contributors to health disparities.
Additionally, this research is also being undertaken at a transitional homeless shelter in San Francisco, California. A medical student from University of California, San Francisco has assisted with data collection (anticipated completion in August 2012). To date, 13 parents have participated in the study.
Putnam defined social capital as social relationships (interpersonal trust, norms of reciprocity, and civic responsibilities) within communities that act as resources for individuals and facilitate collective action for mutual benefit.1 Social capital structures are systems of networks, norms, and trust relationships, which allow communities to address common problems.2
Social capital and health linkages are paltry, but research has shown that higher levels of social capital lead to better health outcomes and lower mortality rates in adults and children.3 Asthma prevalence in the United States is about 8.9% and affects more than 6.8 million children and adolescents.4 Asthma is overrepresented in children living in poverty and asthma rates in homeless children are six times the national average.5,6
Social capital in homeless shelters refers to those structures that facilitate social relationships, interpersonal trust, social engagement, and civic responsibilities. Social capital resources were viewed as case managers, onsite medical clinics, educational programs, and shelter governance meetings.
If we consider that homeless shelters might function as a community, structural features that can stimulate social capital may improve childhood asthma outcomes. Further, engaging homeless families in the tenets of social capital may be the means to facilitate participation in community events when they become permanently housed. Active community participation is essential to bring about the social and physical resources necessary to reduce the detrimental environmental exposures in lower income communities.
Self-rated health and psychological well-being are higher in individuals who reported increased levels of community trust and less political participation such as voting has been associated with poorer self-rated health.7,8,9 Therefore, if homeless shelters provided onsite medical clinics (a social capital resource) would parents rate their children’s asthma as controlled? Encouraging patterns of social engagement with the onsite medical clinic would reduce visits to the emergency room. Further, understanding how social capital interacts with the homeless shelter environments (physical and social) could influence how parents understand or perceive their child’s asthma.
The three shelters were identified by an organization that provides onsite medical services at family shelters. Nineteen parents who had asthmatic children (aged six or older) completed a questionnaire adapted from the American Academy of Pediatrics (v. 3.1; 6/02). The questions covered the child’s health, child’s activities, information about the parent, and information about the shelter. The questionnaire was also translated into Spanish. The questionnaire was read to most of the parents because literacy was a problem.
The researcher, a family nurse practitioner, used the National Heart and Lung Institute’s Guidelines for the Diagnosis and Management of Asthma to determine if the child’s asthma was controlled or uncontrolled and the severity of the child’s asthma (mild, moderate, and severe). The social capital indicators examined were voting patterns and if the shelter had case managers, onsite medical clinic, educational programs, town hall meetings, and governance meetings for the shelter residents.
Self-reported demographic characteristics of the study sample can be found in the images accompanying this article. The questionnaire asked about gender, socioeconomic status indicators (income, education, and occupation), insurance information, and if this was their first time living in a homeless shelter.
All of the homeless shelters had case managers, onsite medical clinics, education programs such as GED preparation, town hall meetings, and shelter governance meetings. Respondents were asked if they were aware of these social capital structures and if they voted and if not, their reasons. About 58% of respondents indicated their awareness of town hall meetings; 21% indicated they did not know about these meetings, and 21% answered don’t know. Most parents knew their case managers (90%), 5% indicated they did not know them, and 5% answered don’t know. Most parents knew about the onsite medical clinic (95%) and only 5% responded don’t know. Parents used the medical clinic (32%) for asthma problems and 58% chose not to use the onsite clinic because the clinic was closed; they brought their child to the ER or to their private clinician. Few parents were aware of educational programs (16%); 47% specified no and 37% responded don’t know. A minority of parents were aware of shelter governance meetings (37%); 26% were unaware of these meetings and 37% answered don’t know. Most respondents voted (68%) whereas 32% indicated they did not vote. Reasons given for not voting were (1) not registered, (2) did not know where to vote, (3) did not know about a particular election, and (4) did not want to vote.
Parents were asked to subjectively assess if their child’s asthma was controlled or uncontrolled and to rate if their child’s asthma was mild, moderate, or severe. Mild was defined as not too bad, moderate was considered bad, and severe was considered very bad. Assessment of the child’s asthma by the researcher was based on the parent’s answers about medication usage and types of medication the child had been prescribed. Cross-tabulations were performed to examine clinician and parental concordance of asthma perceptions and asthma severity.
The clinician and the parent agreed at a 91% rate that the child’s asthma was controlled and 25% that the child’s asthma was uncontrolled. The clinician-parent concordance for asthma severity was 70% for mild, 14.3% for moderate, and 50% for severe.
This small-scale exploratory study was able to quantify that social capital structures existed in family homeless shelters in New York City; however, respondents were more aware of some of these structures than others. Additionally, this study investigated parental perceptions about their child’s asthma because data suggested that social capital may be a determinant in self-rated health and thus could potentially be extended to perceptions about a child’s health status. Further, if the parent sought treatment at the onsite medical clinic, did the parent gain a better understanding of asthma triggers and medications leading to decreased visits to an emergency room?
Theoretically, social capital can broadly examine the structural inequalities that contribute to health disparities. Additionally, social capital may increase our understanding of the associations of homelessness and health problems because linking social capital and health may enable homeless shelters to address cultural norms that are detrimental to health, ensure the adequate provision of health care, and collectively build infrastructures that are conducive to better health outcomes.
References
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