I prefer that the most important problems are put first, if member is moved to hospice contact is very important to the member and family to give support needed.

One thing I have found helpful is being able to understand what the clients needs are. Once correctly identified, I work my way from highest need priority to lowest needs. I rank these needs based off of do they have shelter? Water? Access to clothing? I then work on addressing longer priority needs, such as do they have a natural support system? Do they use it? Understanding the context of client needs exemplifies what I am needing to assist with in these high stress events. My motto is I can go home and not have to worry about it. They have to live it.

Prioritization is crucial and varies depending on the specific setting. In my work with medically fragile populations, I prioritize based on the severity of medical diagnoses and critical lab values. Patients with the most critical lab results and high-risk diagnoses are prioritized on the list. This approach ensures that urgent and high-stakes cases receive immediate attention and care.

The more complex the more information or data is needed from member, family, POA, Guardian or staff to find the correct answers to help the individual process.

Small wins do feel acceptable when juggling larger caseloads that feel they are in a slump. I harken to understanding that less is more. This comes into practice when I am working with complex clients and understanding the more people I am dealing with to meet client needs, the less efficient I can actually be due to potential clogging up of resources. It’s much more efficient when access complexity is much lower.

I work on establishing a baseline for all clients I work with. I like to understand housing needs, natural supports, diet, self care, and monitoring of symptoms. I like to encourage clients to access resources that allow them access to the greater communities and build independence and a network. This ranges from finding housing to establishing a hobby, generally.

I work with vulnerable populations. My approach to each case is to assess the Social Determinants of Health (SDOH) thoroughly. A comprehensive patient-centered evaluation ensures establishing a baseline and uncovering other health-related factors. Sometimes, it's not that the patient is non-compliant; environmental and social factors hinder the patient from accessing necessary care, such as lack of transportation or financial insecurity.

Cases are often mitigated or made worse by the lack of resources. I keep track of the clients needs monthly and understanding resources appear anywhere is vital. Sometimes there are tenacious clients that learn about resources we don’t and being able to learn at the same times as clients is integral to building a resource base that can define a clients success.

As the sole nurse in my department, I have the unique privilege of serving as a home visiting nurse, where collaboration with community partners is key to achieving successful patient outcomes. Caring for medically fragile patients at home, I proactively engage with primary physicians, specialist doctors, clinic nurses, dieticians, physical therapists, pharmacists, social workers, and school nurses to gain a comprehensive understanding of each patient's needs. When conflicting information arises, our interdisciplinary team meetings serve as beacons of clarity, guiding us to provide vital support where needed. This team approach ensures efficient coordination and prevents duplication of tasks across different disciplines.

With my current position TOC CM I have to have others help me with information to complete the TOC if I don’t get the help the job can’t be completed.

I like to plan case prioritization once weekly at a minimum to make sure I am providing adequate care at an adequate pace. I truly believe that things can change at the drop of a hat and this is reflected daily in the lives of the clients I work with. Making sure they have stable supports is essential.