Case managers need to focus on communication
Clients should understand the roles of CMs
Nine years after an automobile accident left her a quadriplegic and seven years after she had a mastectomy following a diagnosis of breast cancer, Janet Brown, RN, BSN, BA, CPHQ, FNAHQ, was surprised to learn that case management services were available through both her independent practice association (IPA) and HMO.
"I have been amazed that at no point in my injury or illness did the IPA delegated by the HMO to provide all care and services ever contact me or do anything for me other than issue or deny authorizations. Even though I have a disabling injury and multiple diagnoses, there is nothing in the computer system, or that of the HMO, that triggers a need for help in navigating the health care system," says Brown, principal of JB Quality Solutions, a Pasadena, CA, health care quality educational company, and past president of the National Association for Healthcare Quality.
It was only when she called to advocate for a woman with multiple sclerosis who had been denied an appropriate, but more expensive, new wheelchair that Brown found out the IPA has a case management division.
"I had been working with this IPA for nine years and I didn't know the case management division existed. I'm a nurse and a quality professional, but it still was difficult for me to coordinate my own care. When you're a patient and you are dealing with the daily impact of a life-changing injury or illness, you need someone to explain the options available within the specific insurance company and help coordinate the next steps," she says.
When her breast cancer recurred two years ago, the hospital case manager communicated directly with a case manager in her IPA.
"The IPA did follow up on me when I was going through the second cancer experience. It was encouraging that there was clearly organized support for breast cancer patients through case management this time, although they were not aware of my spinal cord injury," she says.
Brown's experiences point to a serious lack of communication between case managers and the public and a lack of understanding of the benefits of case management by some managed care administrators, says Cathy Mullahy, RN, BS, CRRN, CCM, president of Options Unlimited, a Huntington, NY, case management company.
"Case managers communicate well, but often it tends to be among ourselves and other people in the health care profession. We want to do a better job communicating with those who need to know we are available," she says.
Often case managers in a managed care organization are working with case managers on the provider side to take care of patients' needs but the patients never know it because they are never brought into the circle of communication, Mullahy points out.
"When I speak at seminars and workshops, it amazes me that there are case management programs where case managers rarely, if ever, speak to the patients," she says.
Case managers need to start educating all health care stakeholders — patients, family members, as well as their own company's administration — about the services they can provide, says Mullahy.
For your company's management, she recommends including personal stories of how a case manager helped a patient in outcomes reports you prepare for in-house administration, she suggests.
"Case management departments need to report on savings and outcomes; at the same time, they need to include anecdotal information with the facts and figures to help their employers see that case management can make a difference."
Case managers, by definition, are clearly responsible for collaborating with patients, families, and health care professionals to promote a good outcome, Mullahy points out. "How can you collaborate with your clients and advocate for them if you're not talking with them?"
If you haven't been talking with the people whose care you're managing, start one case at a time, she suggests. "You'll get better information from a give-and-take conversation with the patient.
"Further, nurses and physicians benefit when case managers share the information gained from talking to the patient," Mullahy adds.
The public needs to know that even if their insurance company doesn't have a case manager they can contract with independent case managers to help them navigate the health care system and choose the best treatment options, she notes.
Any person with a catastrophic injury could benefit from case management. Even in organizations that have case managers, there still are people who fall through the cracks if the patient or family member doesn't ask for a case manager, Mullahy says.
"As case managers, we need to get the word out there so when there is a person with a catastrophic injury or serious illness, they'll know to ask for a case manager," she adds.
Case managers in the insurance industry should learn how they can best be involved in chronic cases and ensure that there is a mechanism for them to be informed when patients need case management, Brown says.
"Based on my experience, it seems that case managers need to make sure the information is accessible to them and that they become accessible to the patient. This will enable them to help walk the patient through the process," she says.
Brown's injury and subsequent illnesses have left her with daily challenges that she's been able to manage with some difficulty because of her background in health care, but she wonders how other people cope if they are bewildered by the health care system.
"I have multiple problems that are chronic. You'd think the company would want to manage my care just for the sake of controlling costs," she explains.
Following Brown's injury, the durable medical equipment vendor helped her get a wheelchair, and the only follow up she had after discharge was from the rehab facility's social worker.
"That's when I could have used a case manager to advocate for me to get me the equipment and services I needed. It's pay now or pay later for the person in a wheelchair. The goal should be to make them as functional as possible and spend money up front, rather than later," Brown says.
Even in situations where the caseload is too high for personal contact with every patient, case managers should look at their cases and start prioritizing those for which patient contact is essential, Mullahy suggests.
"Look at the most complex cases. Start working on those one case at a time and showing that different levels of involvement get different results," she says. In some companies, referrals to case management are diagnosis-driven, but that may not be the best way to select patients whose care needs coordinating, Mullahy adds.
For instance, not every patient with breast cancer needs a case manager. Someone with cancer in the early stages, who has a strong family system and knows how to advocate for herself may not need the services. On the other hand, a patient with no family support group who requires complicated care could benefit from a case manager.
Stratification is the key to a successful case management program because not everybody needs the same approach, Mullahy points out.
For instance, if a patient has a limited pharmacy benefit and needs expensive medication, the case manager should contact the manufacturer to see if there is funding for patients who are underinsured.
Be aware of all the community resources that are available. Even if case managers don't have the time to spend with individual patients, they can refer them to support groups, churches or web sites that provide information and help.
"One role of the case manager is to always encourage self-advocacy in patients. We know that case managers can't always reach out to every individual, but they can see to it that their company's web site includes information on how people can get the help they need," she says.
Brown points out that case managers have the potential to make a huge difference in the lives of their clients by helping them understand our increasingly complex health care system.
"Case managers are a key solution in the health care non-system we have today. They can help manage the patient/client flow, the information flow, and the material throw that make health care either integrated and coordinated or fragmented and dysfunctional. They must advocate for their role as fervently as they are called upon to advocate for their patients and clients," Brown says.
Sources
For more information, contact:
- Janet Brown, RN, BSN, BA, CPHQ, FNAHQ, principal of JB Quality Solutions. E-mail: [email protected].
- Cathy Mullahy, RN, BS, CRRN, CCM, president of Options Unlimited. E-mail: [email protected].
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