Case Management Fellowship Program Helps Improve Case Manager Retention

September 26th, 2024

Program trains to retain

By Melinda Young

An innovative case management fellowship program trains nurses to become case managers who are well-supported as they learn the ropes.

"We're specifically targeting nurses who have been with us for five to seven months," says Katie Rismiller, MSN, an education nurse specialist in the department of care coordination at Nationwide Children's Hospital in Columbus, OH. "That's purposeful because around the six-month mark of anyone having a big life change, there's a period of discovering if it works for me or doesn't work for me," she explains.

"One of the goals of the fellowship is to work on our retention of nurses in the department," Rismiller says. "We want to amp up the support they get to help retain them."

The program appears to work; of the pilot fellows who have reached their two-year mark, there was 100% retainment. This compares with a 68% retainment among non-fellow case managers of similar tenure, she notes. There also is greater confidence and fewer signs of burnout among case managers who were engaged with the fellowship program, she adds.

"From a manager's perspective, they are seeing the fellows as leaders in their role," Rismiller says. "They also are seeking certification in case management to return the favor of mentoring newer staff."

Fellows report feeling more supported and enjoying their fellowship program. They can engage with each other through a work chat software messaging center that allows them to ask each other questions.

"It gives them a safe place to ask those questions, knowing other people are going through those things too," she says.

Creating the fellowship program was time-consuming but not difficult, Rismiller notes. "It's not difficult to find information out there and insert what's specific to case management," she adds.

Rismiller did a research review before planning the fellowship program, and she found a lot of literature about nurse residencies and newly licensed nurses out of college. But there was nothing about formal programs to train nurses to be case managers, she recalls.

"I didn't find any articles supporting the RN's transition from non-case management to case management," she says. "That's what makes this program innovative."

The nurse case management fellows often have a lot of experience in nursing, and they have a self-expectation that they should know what they're doing. But the day-to-day work is very different from being a nurse in a clinic or on a unit, she adds.

The fellowship program is designed to recognize the potential for frustration among experienced nurses who are engaged in case management for the first time. This is why there is educational support for novice case managers, nurturing their professional growth through the stages until they become expert case managers, Rismiller explains.

"I take a list of everyone who is eligible for the program, and based on a conversation they have with their manager, we decide if it's the right program for them," she says. "Our plans are to roll it out to any RN who comes into our department."

Fellowship candidates are case managers who have had one month of onboarding. They also have a preceptor they spend time with between onboarding and the fellowship. They are also part of a team that includes a leader, manager, and educators. "When they join the fellowship, they have a caseload of patients, and we're adding that next level of skill in understanding and application," she says.

Here are the five objectives of the fellowship program:

1. Provide a pathway for experienced nurses to master a new setting.

During the fellowship, which lasts one year, case managers have monthly to-do items, including a one-hour learning session that focuses on case management and nursing skills.

"They do one our of professional development, related to the topic of the month," Rismiller says. "And they are paired with a mentor who is a certified case manager, and they meet with their mentor once a month for at least 30 minutes."

Each fellowship case manager also completes a monthly three-question self-reflection in a journal they received on the first day of their fellowship. "Then, the last thing, one of the biggest things in any role that reflects retention of staff in general, is acculturation in the institution," Rismiller says. "They have a session each month that focuses on various things, including benefits to employees of the institution."

Other areas of focus are volunteer opportunities related to the work they do in the hospital. "We take tours of places in the hospital that they may talk with patients about," she explains. "Like the Ronald McDonald house, which is amazing. A lot of their job is explaining how families can stay there for free while their child is in the hospital."

Before the fellowship program, not many members of the staff had seen the Ronald McDonald house, even though they would recommend it to families, she adds.

The last three months of the fellowship are focused on a miniature lit review or an evidence-based practice project. "They work as a team or teams to research a topic they have identified as something that could be improved in their role or pertaining to their role," Rismiller explains. "They read through the literature review and pull out main themes and propose a solution for whatever problem they're facing, and they propose that to the leadership staff." This helps facilitate their growth as a case manager, she adds.

2. Establish habits for maintaining emotional wellbeing.

"Institutionally at Nationwide Children's, we have a heavy focus on staff well-being in general," Rismiller says. "Also, in this stage of change, shifting to a new role of case manager, which institutes a lot of stress, we blended that focus to take a trauma-informed approach to staff and patients."

For example, the fellowship participants can take a class on how to build a terrarium to put at their desk station.

"Even seeing a tiny bit of nature day-to-day reduces stress long-term, studies show," she says. "We also have them put a specific block of time on their calendar, every day, to remind them to step away from the computer and do something away from the screen."

They can commit to a yoga session, mindfulness, going for a walk, or even staring out the window, if they like. "They just need to get away from the computer screen," Rismiller says. "The expectation we may have for ourselves is to keep working, and we know that's not creating an efficient day-to-day workflow."

3. Identify strategies to improve work efficiency.

An example of how to improve work efficiency involves finding shortcuts to documentation in the electronic health record. "During onboarding in the first 30 days, they get the bare minimum in how to operate that system," Rismiller says. "So, we teach them strategies to increase efficiency for documentation, and one of these is to create shortcuts for things you put in the chart all the time."

An example would be how they type in their name. Instead of writing their name out, they could just use their initials, she says.

"We also look at prioritization and delegation to increase efficiency," she says. "We talk through scenarios, saying, 'If this came up, how would you reprioritize?'"

Each nurse case manager has a case management extender or a medical social worker who can help them with their patient caseload. "We find that staff struggles with understanding the delegation in case management," Rismiller says. "Delegation when they were in their inpatient role was more straightforward: unlicensed staff would do the same thing over and over, like bedside work."

Case management is different, so the fellowship program discusses how case managers can delegate tasks to their partners, efficiently and successfully. For example, a case manager may have a call scheduled with a patient at 10 a.m. to see how they're doing. But 15 minutes before the scheduled call, another patient calls with a crisis that is time sensitive. The case manager can ask their partner to make the 10 a.m. call for them so they can handle the more complex problem that arose, Rismiller explains.

"Some tasks only licensed staff are allowed to do, by law, so we rely heavily on support we have from our teammate to get everything done for the day," she adds.

4. Demonstrate professional growth within the area of case management.

"Personal growth occurs with one hour of professional development each month," she says. "For example, when we are focusing on efficiency and effectiveness that month, we may have them take a module on managing time." They would take the module outside of regular class time.

"They continue to do an hour of continuing education each month," Rismiller says.

The program assesses their professional growth through measuring their chart audit scores and with leadership staff reviews each quarter, she says. "We compare the chart audit scores of the fellows with other case management staff that are not in the fellowship program, and the fellowship case managers had higher scores," she adds.

"We also measure their patient satisfaction survey results, using a random survey of around 300 patients each quarter, and we compare the results of the fellows to other staff with similar tenure."

Those scores also proved to be higher for the fellows, she says. "We also track how many continuing education credits they got with what non-fellows did, and the fellows achieved more than non-fellows," Rismiller says.

5. Increase patient and nurse satisfaction.

"For me, what was important was putting a heavy focus on staff satisfaction," she says. "There is long-standing literature-based proof that there is a correlation between staff satisfaction and patient satisfaction — if you make staff happy, you make patients happy."

The mentorship helps with staff satisfaction. "One thing we heard before the fellowship is they had that month of onboarding, but after that they didn't feel like they had the full support of a single person," Rismiller explains. "Having the mentorship helps increase their satisfaction."

Staff collaboration also can help. "If we have something that's not in the wheelhouse of the nurse, then who is the expert in that area?" she says. "And how can we connect patients with them?"

Fellows learn about the roles of staff in other departments to have a better idea of what everybody's expertise is. "We also talk about how from the patient's perspective, health care is complex, and there's a chance for error, and here's how to avoid error," Rismiller says.