Case management professionals typically work with a variety of people from day to day, and the work is broad and diverse.
For some patients, there exists certain health disparities — “preventable differences in the burden of disease, injury, violence, or in opportunities to achieve optimal health experienced by socially disadvantaged racial, ethnic, and other population groups, and communities,” as defined by the CDC.1 Case managers are in a unique position to address these challenges as they serve as a more concrete bridge between healthcare and the patient.
“[The definition] speaks to gaps that are unjust or avoidable, or unfair,” explains Laurie Signorelli, DBH, MSW, LMSW, AC, consultant for the Center for Case Management. “There is also a difference between equality and equity. In the U.S., we are speaking more of barrier eradication.”
Kiandra Florence, a journalist covering health disparities among minority groups in America, agrees, adding health equity is concerned with “connecting people with the resources that they deserve.”
She also notes there is a “fine line when it comes to opportunities for everyone to reach their full potential, and it depends on resources and things that are available to them.”
Since the topic itself can be contentious, many believe it is best to focus on what can be done at any given level to minimize the effects of these health disparities and help close the gaps in opportunities for appropriate healthcare.
“It’s such a multilayered and multifaceted thing that moves from the basics of what case management tries to do to effect the health and outcomes for an individual patient, to a larger scale like community development, then to advocacy around national pollicies,” Signorelli says. “But addressing the barriers to care — even transportation can be a barrier to healthcare — is important because there are so many aspects of health that are intertwined in order to gain equity for a population.”
Understanding the Barriers
Florence, who has primarily studied the Black population’s access to healthcare, notes the importance of finding “providers who are understanding of cultural barriers.”
There is a difference between practical barriers and personal barriers, she says, but both need to be acknowledged and addressed to help move people toward receiving appropriate healthcare — and, hopefully, achieving their own personal best health possible.
According to Signorelli and Florence, practical barriers include:
- Inadequate access to basic needs like food, heat, cooling, shelter, transportation, and safety due to violence, trauma, neglect, or exploitation. “If patients are worried about these things, it’s simply hard to focus on following a treatment regimen,” Signorelli says.
- Mental health issues.
- Substance abuse issues. According to a report from the Kaiser Family Foundation, Mental health and substance use disorders together were the leading cause of disease burden in 2015, more so than cardiovascular disease and cancer.2
- Health literacy.
- Education.
- Health behaviors, such as exercise, walking, etc.
- Social isolation, especially for elderly people. “We saw this during COVID,” Signorelli adds. “It greatly impairs access to healthcare.”
- Lack of support from state governments, including lack of funding
- Portability of insurance. “Many private insurances and state Medicaid do not work when patients cross state borders,” Signorelli notes. “If you have someone coming in from a neighboring state with Medicaid and they need a nursing facility, they may not pay for it as it needs to be in their own state. That creates a barrier for getting the access that they need.”
There also is a focus on personal barriers to healthcare, which vary from person to person. “The first is mistrust, which comes from years of abuse in the medical system for people of color and [those in] low socioeconomic parts of society,” Florence explains. “With people of color, there is distrust that the [COVID] vaccine is actually going to help because of a history of medical providers illegally practicing on Black people, like in the Tuskegee Experiment.”
For some patients, Florence says, symptoms are neglected or dismissed due to a myth that people of color have a higher tolerance for pain. Patients of color, especially those with a history of abuse or trauma, often are “more comfortable working with providers who look like them and talk like them, but there is a lack of access to people like that who understand,” she notes. “If someone does not look like you, or represent you, it’s a hard barrier to get over. They may feel that if they see only white doctors, there is no care there for them.”
Some patients might experience a similar situation when it comes to the religious aspect of some hospitals. “So many hospitals are Christian or Catholic hospitals, and there can be a stigma that comes with that,” Florence says. “There are studies that show that with Black and Hispanic people, there can be a stigma around mental health — in their religion, they’re taught to follow through with the church and seek guidance and relief there, not seek out professional counseling.”
These hospital structures often “cater more to those with Christian beliefs, which adds to the mistrust and lack of representation,” Florence adds.
“If they don’t relate, they might not open up as much,” she says. “That can be another barrier between the healthcare provider and the patient.”
Unconscious bias can play a part in the reception of appropriate healthcare, even among case managers.
For example, “One’s perception that they have seen something happen more often with people of color than they have with Caucasian, middle-class people, predisposition to violence or substance usage, or one’s perceptions of people of color or those from a cultures not their own, can impact their quality of care,” Signorelli says. “Another example might be the perception that someone with a history of substance abuse is automatically drug-seeking, even if they have a real need for pain medication.”
Who and Where
Both Florence and Signorelli agree those most affected by these barriers include people of color and the socioeconomically disadvantaged, as well as those who are living in:
- impoverished areas or an area considered a food desert;
- non-healthy environments, like spaces with many fast food restaurants;
- unsafe neighborhoods with high crime rates;
- places with little to no access to mental health or medical facilities.
“A lot of this is happening in urban areas, where there is a lot more people of color represented,” Florence says. “In these areas, people often have a lack of access to mental health facilities because the nearest one is 30 or 40 minutes away, and there is no bus access. Often, this is the area that suffers the most with mental health issues, especially among the homeless population.”
In some areas, Signorelli says, homeless shelters are “set far away from community services that people need,” or mental health facility “waiting lists go on and on forever and never meet the need of the population.”
In some places, care coordinators can struggle to schedule appointments or care for people that simply meet their basic needs, she says.
Case Management’s Role
Case management professionals can help mitigate some of these barriers and challenges just by staying mindful within their own role and taking the time to care for the patient as a whole person.
“Evaluations are very important,” Signorelli explains. “We’re particularly charged with looking at all social determinants of health, including healthcare literacy and education. We know that an informed patient is in a much better place.”
Likewise, planning ahead and broadly can help case managers provide the best possible care to all people, but those who are especially affected by these barriers. It also helps to be sensitive to the experiences of others, even if those experiences are unlike the case manager’s own.
“As a case manager, I have to start from where the patient and family are based on their experience,” Signorelli says. “Case managers are in a position to be able to get people the right information so that they can make a good decision. They can tailor the patient’s plan to the outcome of the assessment.”
Signorelli also recommends case managers go above and beyond when planning for their patients.
“If possible, do a more robust plan,” she adds. “If the patient is stable, ask, ‘Do they have the right services? Will anything pose an issue to them in following their plan of care?’ Look more in depth and consider both a short-term and long-term plan. We have to ask, ‘What’s the plan after the first 30 days of medication runs out?’ Case managers should think longitudinally about attacking those barriers.”
It also is important for case managers to establish good connections and networks throughout the community so they can provide their patients with the best possible opportunities while minimizing barriers.
“Many facilities are in value-based care arrangements,” Signorelli explains. “Reimbursement streams reward efficient care and collaboration for care. Case management leaders are a very integral part of identifying gaps in the community and in other leadership. They can work to organize those networks and collaboratives, eradicating those gaps.”
For example, “If only one place in the community can take someone with dementia and the beds are usually full, how can you look together with people in the community to solve this problem?” she asks. “Community leaders are often at the forefront, looking for these gaps, and case managers can help play a part.”
Simple Compassion and Empathy
The case management role is about more than just planning for discharge.
“It’s a plan of care, education, resource allocation, and it all starts with the person we are there to serve,” Signorelli says. “We have to put the person at the center, who they are, what their goals are, what resources and information they are going to need. If we remember this, we’ll be in a better position for advocating for them.”
Likewise, Florence describes how a little empathy goes a long way.
“It’s so intertwined,” she says. “If you have someone leading the care and compassion in leadership, if you’re a leader of a case management department and you’re seeing these issues, be the change. Advocate for the patient in the best way possible. Go the distance for them. Speak to leadership. Take control over the lack of care that you’re seeing. Be the change you want to see.”
Signorelli acknowledges “when people are feeling pressure, empathy often goes right out the window. There can be lots of pressure on length of stay and more. But it all starts with compassion and empathy. These are people, not widgets. We have to be mentors in this regard.”
There are many benefits to showing compassion and empathy, even in the difficult or stressful moments of healthcare. Doing so can make positive changes that reverberate throughout the community.
“Listening goes a long way, and there is a difference between hearing someone and listening to them,” Florence shares. “Case managers are in a high-stress environment, but being sure to listen will lead to being more apt to understand the patient and do what is needed to truly help them. It helps address mistrust issues when [healthcare providers are] being more understanding. When you learn more about who you’re working with, and who is involved in the community, it might lead to case managers going to other departments in the hospital and taking the initiative in areas where they can’t make the change alone.”
Signorelli agrees, adding, “We have to have an extensive knowledge of resources, of course, but we have to first understand the needs of the person.”
The good news she says, is “we are more alike than different.”
“Most people want safety, comfort, food, and shelter. Think about the commonality of the human experience and look at everyone that way,” Signorelli says. “It really helps toward having compassion and understanding for someone whose experience may be different than your own.”
REFERENCES
- Centers for Disease Control and Prevention. Health disparities. Updated Jan. 31, 2017.
- Kaiser Family Foundation. Visualizing health policy: The costs and outcomes of mental health and substance use disorders in the US. Aug. 1, 2017.
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