Career Perspectives

Psychiatric Nursing Positions in Managed Care

Kris Nash, BSN, RN

Career Perspectives discusses alternative careers for psychiatric nurses. This column explains the variety of roles for nurses in a managed care organization, and outlines two of the more common and important roles of precertification nurse and case manager.

UR Nurse wanted for behavioral health case man- agement. Managed Care Behavioral Health Orga- nization seeks psychiatric nurse-UM experience preferred.

Employment ads with puzzling acronyms seem to crop up with increased frequency as managed care and HMOs increasingly become the most common type of health insurance coverage for Americans. More than 78 million Americans are now covered by HMOs, a number that is predicted to rise 28% by the year 2005 to more than 100 million (Sussman, 2000).

The most effective organizations focus on keeping pa- tients healthy by emphasizing preventive care and pro- viding a holistic range of benefits. They have strong quality-improvement programs and offer a variety of disease-management programs. They have well-trained and effective case managers and visionary leadership. They constantly strive to improve the process. The lead- ers think “outside the box” and listen to their stakehold- ers (members, providers, employees). Traditional indem- nity insurance is fast becoming a dim memory for many, and it is completely unknown to many entering the job market today. Like it or not, managed care in some form appears to be here to stay. Where do nurses fit in today’s managed care organizations?

As hospital beds decrease in number and psychiatric and substance abuse centers close their doors, many nurses, particularly those in more rural areas, are forced to consider a career switch from the traditional role of hospital-based nursing. Managed care organizations in- creasingly present unique job opportunities for nurses, with many new positions that did not exist 5 years ago. Many are niches carved out by nurses themselves who recognized gaps in the managed care process or an un- fulfilled need in the organizations.

Nurses work in many areas of managed care-for ex- ample, utilization review, quality management, claims review, network management, and member educa- tion/health improvement. Nurses also write policy and procedures; conduct internal and external audits for reg- ulatory compliance; or work in legal and risk manage- ment, provider relations, coordination of care, and case management, to name just a few. Behavioral health may be done in-house by a behavioral health vendor who specializes in this area, or by an insurance company that creates a wholly owned subsidiary specifically for this purpose. This article will address utilization manage- ment, or utilization review and case management, in a managed care environment. Both are areas that usually require at least an RN license. Many organizations prefer a master’s or licensed professional counselor degree. De- partment directors and clinical management positions may require a doctorate.

Utilization Reviewmanagement

One way HMOs manage care is through utilization review (UR), also referred to as utilization management (UM). UM often is considered the ”nerve center” of the HMO, as cost of care consumes on average 80% of the premium dollar and is the most crucial financial aspect of the HMO’s bottom line. The demand is rising for skilled nurses with medical and/or psychiatric nursing experience to fill these positions. At its most basic, UR consists of reviewing clinical information and making a determination of medical necessity within coverage guidelines using established criteria.

Behavioral health presents unique challenges to the nurse reviewer, because the clinical information pre- sented tends to be subjective rather than medical criteria, which are normally objective, and measurable clinical data. Additionally, many states have confidentiality laws that limit the amount of information that can be given to behavioral health UM to determine medical necessity.

Despite recent passage of parity laws, many plans continue to have limited benefit coverage. One of the most common benefit structures seen for behavioral

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Career Perspectives

health is 30 days for inpatient care and 20 outpatient vis- its per calendar year for commercial plans. Medicare benefits are more liberal but still have limitations. Some plans limit the number of times a member may enter a substance abuse treatment center, rationalizing that by offering coverage for unlimited admissions, the em- ployer group or health plan becomes part of the enabling process. All these limitations must be taken into consid- eration when determining the appropriateness of care. Experienced nurses can assess the appropriate level of care and determine in-patient or a lesser level of care.

A facet of the process that may be new or uncomfort- able to nurses unfamiliar with managed care is basing au- thorizations for a requested service on the amount of ben- efits available. Although care may be medically necessary, a patient may be near the end of his or her benefit limit or have exhausted benefits for the year. This requires creativ- ity and a good understanding of community resources to effectively manage care for this patient until the new bene- fit year arrives. Nurses make determinations based on the pdelines established by the organization, usually under the direction of an appointed medical director. The guide- lines may be nationally accepted, created in-house, or be a combination of the two. There are several roles a nurse may fill in the UM process. Precertification and case man- agement are two of the most common.

Precertification. A precertification nurse may take in- coming telephone calls from members, providers, hospi- tals, or primary care physicians. The nurse also may re- ceive faxed or written referrals for requests for care. The nurse performs triage, processes intake information, checks eligibility and coverage, and assesses the caller’s need-everything from a simple referral for a diagnostic assessment to a need for immediate police action, refer- ral to case management, or immediate hospitalization. This position is referred to by different names: intake co- ordinator, precertification nurse, or clinical coordinator, to name a few. In any case, this nurse is the first line for the variety of daily calls and must possess excellent triage, assessment, and communication skills.

Increasingly, a nurse who is bilingual brings added value to the position. This position brings many chal-

lenges, as well as rewards. Many callers have never had to ask for help, particularly for a mental health diagnosis. Members report they did not know where to start. Many are in crisis or trying to help a family member in crisis and do not know where to turn. The member may have lost a spouse or a job. Callers may be intoxicated, irra- tional, or demanding. Some callers report they have tried to muster up the courage to call for days prior to the ac- tual call, and a nurse who can truly listen, and provide information in a calm, reassuring and friendly manner, can make all the difference. It’s all in a day’s work in this position.

Case management. A case manager’s role may be a hybrid, depending on the structure of the organization. The basic educational requirements for this position can differ. A registered nurse, certified case manager, a li- censed professional counselor, nurse practitioner, PhD, or a combination of these may function in this role. The case manager may perform the dual role of intake coordinator and case manager, or may function strictly in the role of case manager for those members who require more than simple referrals for counseling and medication.

Many nurses rely on established clinical pathways to coordinate the continuum of care. Clinical pathways-r best-practice guidelines as they are sometimes called- help guide care by mapping out interventions in a way that provides best patient outcomes. These guidelines often include post-acute services, discharge planning, and community resources. In the case of behavioral health, the limitation of benefits creates an even more pressing need to maximize care.

Inappropriate hospitalization, referrals to therapists who are a poor match for a member’s needs, and inap- propriate levels of care are areas that require interven- tion from a case manager. HMOs traditionally did not include members with diagnoses of severely or persis- tently chronically mentally ill until the last few years, when Medicare enrollees entered managed care organizations. The diagnoses of schizophrenia and bipolar disorder with psychosis were relatively rare for HMO case managers until recently. Medicare enrollees have created a need for more intense case management.

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Sometimes known as assertive case managers, these nurses work closely with members and their families to ensure continuity of care and focus on outpatient follow- up after hospitalization, management of medications, cc- ordination of home care visits, and arrangement of trans- portation to appointments if necessary. These case managers tend to work closely with community re- sources because members often use community or county-based mental health centers. Continuity and con- tinuum of care are the basis of case management. Fol- lowing the continuum of care and averting the need for repeated hospitalizations or preventing relapse are the best outcomes.

Nurses also play an enormous role in ensuring patient compliance. Research shows that patient compliance is an even more sigruficant factor than previously thought. A recent study found that 50% of medications prescribed for chronic conditions are never taken (Weibe, 1999). Pa- tients need to understand why and how something will work for them. Nurse case managers can provide the ed- ucation needed to attain compliance.

Case managers, who often come to know these mem- bers and their families on a first-name basis, become cru- cial in the patient's path to wellness or enhanced quality of Me. Case managers also play an important role in con- tinuity of care by integrating medical and behavioral health. The nurse may be able to recognize how a medi-

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cal condition can mimic or exacerbate a mental illness and take steps to make providers aware of a patient's medical status. The HMO may be able to provide a list of all medications prescribed for the patient, thereby giving a more complete picture of the patient. These are but a few examples of the importance of the case manager's role. It is a demanding but ultimately graidymg role and a crucial position in the managed care organization.

In sum, nurses are poised to assume many different roles in managed care. Precertification and case manage- ment are two of these positions. As society strives to cre- ate a workable healthcare system, the nurse's clinical background, communication skills, and expertise will continue to play an increasingly important role in creat- ing an efficient, compassionate, and equitable system.

Kris Nash, BSN, RN Delegation Management Consultant,

Pacificare of Texas, Dallas, TX

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12ll -t S t r e e t PhiI&d@ua, PA 19101-5409

1211 -t street phrl~el&ia, PA 19107-5409

Author contact: nashintx@home.com, with a copy to the Editor: mary77@concentric.net

References Sussman, Diane (2000). Generation Rx. HealthWeek, 5(16), 21. Weibe, C. (1999). Following orders. American Medical News, 42(47), 27.

Key words: Alternative careers, case management, managed care, precert $cation

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