“Snapshots” of Contemporary RN Case Manager Graduates in Practice

In my leadership role as the Executive Director for Care Coordination, I am responsible for assuring the successful  coordination of care across multiple settings.  With a team of talented Nurses, Clinical Care Coordinators, Geriatric Patient Navigators, Social Workers, and Support Staff, we assure that patients receive the necessary level of care, in the most appropriate setting with an emphasis on patient preferences and meeting individualized goals of care.    One of the unique services we offer to our patients, is the LINCT Program (Liaison in Nursing Care Transitions).  Dedicated LINCT Nurses focus specifically on care coordination at the time of transition to SNFs to assure complete hand-off of information, continuation of care plans at the next site of care delivery, and a seamless experience for patients.  The primary goals of the LINCT  Program are to decrease unnecessary hospital readmissions, impact likelihood of patients returning home post-hospitalization, and achieving a high level of satisfaction through a collaborative approach to care coordination across the continuum." — Arlington Heights, Illinois; Graduated March 2015

Dina Lipowich, RN, MSN, NEA-BC

Executive Director of Care Coordination, Northwest Community Hospital

As an RN Care Coordinator for a medical practice I work with a high risk population with multiple chronic illnesses that are at risk for hospital readmission.  A big part of what I do is chronic care management that includes helping patients and their care givers self- manage their chronic conditions. " — Green Bay, Wisconsin, Graduated June 2015 Kim Bayerl, RN, BSN

RN Care Coordinator, Bellin Health

As a TB Case Manager for the public health department I provide care coordination for clients with active tuberculosis including extensive collaboration with a network of primary care and specialty providers, labs and state and regional TB consultants.” — Madison, Wisconsin, Graduated Sept 2014   Julia Greenleaf, RN, MPH

TB Case Manager, Madison and Dane County Public Health

As an RN Case Manager in a rural critical access hospital, I meet with patients in the hospital to ensure a smooth transition of care at discharge.  This might entail providing education on a new diagnosis, informing them of community resources, arranging for in-home services, or making sure they have transportation to their next medical appointment.  I work with an interdisciplinary team on reducing our readmission rate.  Each patient I see is assessed for readmission risk factors.  Patients found to be at increased risk may need sooner follow up appointments or may qualify for skilled nursing services through a home health agency.  We have recently started making follow up phone calls to all patients discharged from our inpatient units.  Within 48 hours of discharge, a call is made to ensure the patient has an understanding of their instructions for home, has filled their prescriptions, and is managing well after the hospital stay.  Medications and symptom management are reviewed and the patient is reminded of upcoming appointments.” — Dodgeville, Wisconsin, Graduated Sept. 2014 Amy Haesler, RN, BSN

RN Case Manager, Patient and Family Services , Upland Hills Health

The role of RN Case Manager is one that continues to evolve here at Upland Hills Health.  In a small hospital providing care in a rural community, we have to be flexible and willing to wear many hats.  No two days are ever the same which can be challenging, but also exciting.  The future looks bright!  Our goal is to look at expanding the Case Management role and to stay abreast of the changes in our healthcare system.  This may include greater collaboration with our clinics on chronic care management.  It may also potentially include looking at providing a transitional care management visit in the home to follow up with at risk patients discharged from the hospital.”  — Dodgeville, Wisconsin, Graduated Sept. 2014 Lynn Hebgen, RN, BSN

Chief Nursing Officer, Upland Hills Health

I have had two positions as a case manager – one as Inpatient Nurse Case Manager of chronic psychiatric patients and the second working with chronic psychiatric patients, children and adults, to help them manage their conditions at home to decrease their hospitalizations.  Currently I work with Veterans with chronic conditions (i.e. CHF, COPD, DM, HTN) as well as chronic mental health conditions to help them manage their conditions at home.” — Roseburg, Oregon, Graduated February 2016   Donna Scott, RN

RN Case Manager – Chronic Conditions including Mental Health, Roseburg VA Medical Center

As an RN Case Manager I work with a chronically ill employee population providing self-management support and care coordination services." — Chicago, Illinois; Graduated October 2014

Rachel Kirsch, RN, MSN, CCM

RN Care Coordinator, RUSH Health

As a Transition Care RN I work with patients admitted to the hospital who are at high risk for readmission.  I work to coordinate care for patients and families as they are discharged back into the community making sure that they have the services and support needed to ensure continuity of care and support management of chronic conditions.”  — Lake Forest, Illinois

Kristine Sickels, RN, BSN

Transition Care RN, Upland Hills Health

I am the Chronic Care Manager of the Readmission Reduction Program.  I am responsible for coordinating care and the telehealth program.  I provide daily health coaching to support patients in the management of their chronic conditions.  I coordinate care between home health agencies, primary care providers and specialists.” — Valdosta, Georgia; Graduated December 2015 

Tammy Steverson, RN

Chronic Care Manager, Readmission Reduction Program

As a Home Telehealth Care Coordinator I assess and interact with veterans on a daily basis using telehealth technology.  I utilize data sent from these veterans via their landline, cell phone, or internet service thru a specialized health monitoring program that I access from my office which allows me to assess and manage their chronic medical conditions on a daily basis.  Follow up phone communication allows me to interact with the veteran to determine if the veteran is in need of immediate assistance and/or ongoing care via concentrated case management.  I have a set panel of patients and become very familiar with them and their caregivers. As Home Telehealth Care Coordinators-Case Managers we work to ensure that health problems are being managed effectively and efficiently to improve the quality of life for our veterans.  I practice at the top of the scope of my practice and utilize all of my nursing skills and various “hats” to think inside and outside of the box to case manage and care for these veterans to the fullest extent of my abilities by identifying and utilizing all possible VA and public services available. We provide the Right Care to the Right Veteran at the Right Time for the Right Reason because…. Veterans Matter!" — Roseburg, Oregon, Graduated February 2016

Dayna Kaney, RN, BSN

Home Telehealth Care Coordinator, Roseburg VA Healthcare System