Nurses in USA moving to new type of job in Care Management

Main Category: Nursing / Midwifery
Article Date: 20 Jan 2004 - 0:00 PDT

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More and more nursing are leaving their traditional jobs (hospitals, clinics and nursing homes) to work for insurance companies (and health benefit administrators). They provide patient education and care management by phone.

In the USA the percentage of nurses doing this type of work now stands at 3.6% (percentage of all nurses). The majority, three-quarters, still work in traditional settings (hospitals, clinics and nursing homes).

As care management costs rise the number of nursing jobs outside these traditional posts are rising fast.

What is Care Management?

Care management means helping patients through the maze of care decisions and insurance rules. It is an important method of keeping a lid on costs (which are rising very quickly).

'I think now the health care system has gotten so complex that a case manager has to be there to just manage the disease process,' said Jane Wolf, director of the health services department for Security Health Plan, the insurance division of Marshfield Clinic. 'In a way, we are the concierge of health care.'

Security Health Plan has a staff of 22 that deals with care management, 11 of them nurses. WPS Health Insurance, which is in the process of hiring 600 claims processors in Wausau, has 33 nurses on staff - six of them in Wausau. Care management company, Avidyn Health, formed by the parent company of Wausau Benefits last week, has more than 60 people on staff in Wausau from the former Wausau Benefits care management group.

Those numbers are small compared with the 500 nurses who work at Community Health Care Wausau Hospital and about 800 nurses who work at Saint Joseph's Hospital in Marshfield. But the growth in care management jobs for nurses is making slow but steady progress.

The nursing staff at Avidyn grew from just two nurses in 1979 to more than 60 today, said Randy Jefferson, 55, Avidyn's Wausau group director, reflecting the 'huge growth' in care management.

'Case management and disease management have always been part of what we've done,' Jefferson said.

'One of the challenges now is sorting through all the information that's out there. Our approach is to get people to take responsibility for their own care, to get people to recognize that they can make a difference. And giving good information is a key part of that.'

Nursing skills are a necessity for much of what is done in the care management groups at health insurance companies and benefit administrators.

The difference is in the hours worked - generally 9 to 5, Monday through Friday - and in the way nurses interact with a much higher number of patients: by phone, e-mail or regular mail.

'I think we all see it as an extension of direct care,' Wolf said. 'A lot of times the image is that we are here for the purpose of denying care. But our purpose really is to eliminate inappropriate care. When nurses get into this role they find that they make a difference in a whole different way.'

Wolf, of Security Health Plan, said she sees her role as 'enhancing care' that doctors provide.

After years of hands-on experience with patients, the nurses at insurance companies and benefit administrators use their experiences to help patients through the often confusing and complex health care system. Many find it just as rewarding.

'I'm still working for the patient,' said Melissa Degoede, 36, a registered nurse and clinical manager at Avidyn. 'I'm still trying to give a sense of well-being to the customer and get them through the system.

'I'm doing as much or more for them than I could in a clinical setting. The difference is that here I have the time and the resources to get things done.' Degoede has worked for Avidyn (and Wausau Benefits) for six years. She went to school to do patient care but decided to try something different after working in a hospital for 11 years.

'It was a hard decision,' she said. She wanted to still use her nursing skills, but she also wanted to leave behind the 12-hour shifts and obligation to work holidays and weekends.

Dawn Borgwardt, 35, a registered nurse who is senior managed care coordinator at WPS Health Insurance in Wausau, said her job has been educational. She has a background in nursing home and hospital care but has been with WPS for four years.

'You understand the (health care) system much more,' she said. 'You wouldn't be able to do this job without a clinical background.'

The average nursing student today starts out just as Degoede did. Nearly all of the students at Northcentral Technical College who enter the work force after graduating will work at a hospital or clinic, said Lynn Schneider, an instructor. Their average age is between 27 and 30, she said.

'The majority want to do patient care,' Schneider said. 'But one of the neat things about nursing is that there are all those options out there. You can choose a different path without having to really be retrained.'

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