Case managers who work with patients managing substance use disorders have a unique story to tell and wisdom to share. Facilitating difficult situations day after day can be described as a journey with much to learn along the way. Michelle Dodson, MA, MSW, CHt, LCSW, strategic program manager of care management for AdventHealth, and Kelli Burba, BSN,RN, ACM-RN, executive director for care management for AdventHealth, have walked this road for many years.
Dodson’s focus has been on leading “a team of licensed clinical social workers who journey with patients through their time at the hospital.” She works to connect these patients with treatment for their substance use disorders. Burba has been in this field since the late 1980s and is a wealth of information for case managers working with patients battling substance use disorder.
For Dodson, meeting patients when they arrive and building rapport is the first step.
“I check in with them throughout their stay and learn their stories,” she explains. “We develop clinical relationships more so than when in frontline case management, and we don’t expect to discharge them and then never see them again.”
With hospital-provided work cellphones, Dodson and her team can stay in touch with those who are interested, usually via text. “We provide information that way on support groups and agencies to these patients, and work to advocate for their needs when in withdrawal,” she says.
The journey often includes seeing patients through many life events, like becoming sober, marrying, or finding a job. “We get to see the other side of the hard work and the results that we wouldn’t otherwise get to see post-discharge,” Dodson says. “It’s long-term rapport-building.”
Building this rapport does not come naturally to every case manager or social worker.
“Everyone’s way of building rapport is different,” Dodson notes. “It depends on showing your human and authentic self, finding something about the patient that you can connect with them on, and even taking risks to connect to the patients where they’re at. They can tell when you’re being fake and can pick up on that right away.”
“Being truthful and honest with the patient, letting them see yourself, makes a difference,” Burba adds. “There can be lots of escalation when people are frustrated. When they come into my office, sometimes hot and heavy, the surroundings cause them to pause to debrief a second. They see pictures of horses around them, and it kind of clicks and softens them just a moment. It’s one way to be very human with them.”
When patients arrive and are escalated in the ED, Dodson often calms the situation simply by knowing the “regulars” and being familiar with their stories.
“When you ask about their family, and perhaps share something of your life, it’s distracting — in a good way — and can throw them off from what they’re irritated about,” Dodson explains.
This extra work with patients does mean it is not a nine-to-five job, and case managers are somewhat connected all hours of the day and night. But the benefits to the patient are endless.
“However, it is so important to have these texting capabilities because often these patients don’t want to talk on the phone with you, but they want to text,” Burba says. “All teams should look into offering this option, and the phones are HIPAA compliant and secure.”
“With this population, unlike with regular case management, you can’t always just give the patient a printed list, send them on their way, and hope for the best,” Dodson adds. “The list quickly gets outdated, funding has changed, or phone numbers are not working. It helps to develop relationships [in the community] and know who to call for favors or to help get a bed for a patient. It can be very different learning the referral process for all these patients, but developing relationships with the community can mean huge growth.”
If a texting option is chosen — with clear boundaries in place and the ability to block or transfer a patient to the care of another team member, if needed — Dodson notes clinicians who set boundaries while retaining a great work ethic are successful in meeting the needs of patients with substance use disorders.
Recognizing the Need
Dodson notes early identification is important, but not every hospital has the resources and staff to provide precisely the level of care needed. In those cases, do not get discouraged, but rather help the patient stay for the medical treatment they need, consistently ask why they might want to leave, and ask what the staff can do to keep them comfortable and address their needs.
Dodson recommends patients with substance use disorders and case managers work together to create a treatment plan. “They need a plan that works within their parameters, their transportation needs, etc., that they will actually do,” she explains.
If the plan does not take the first time — or the first several times — case managers should not be discouraged. “It takes an average of eight years to maintain long-term sobriety, and you may see five admissions straight before they are ready and able to maintain the plan,” Dodson notes. “They will often relapse and start over. The team should be aware of this possibility. They should not lose hope because this time might be different — the patient might be ready.”
Throughout the process, it is important to recognize those who might be in withdrawal. Dodson notes they may be belligerent or easily frustrated, but case managers should make sure to “treat them like humans and without judgment, connecting them with the resources they need.”
Sometimes, this takes education for the case manager and the team, learning to be extremely observant and always seeking to do the very best for this unique population while avoiding isolating or labeling the patients, Burba says. Often, it might be necessary to work closely and collaboratively with a social worker so the case manager is not “too siloed” when it comes to the mental and behavioral health side of patient care.
Both Dodson and Burba acknowledge patients managing substance use disorders can be challenging, but that consciously working to avoid promoting a stigma can help both the patient and the team caring for them.
“This population is not the easiest to work with, and often you have repeat offenders,” Burba says. “You’re trying to get them to stay sober and care for them, but it can be frustrating. Many don’t have a payer source, or there is nowhere for these people to go. Still, building relationships is key, and the main thing is to avoid the labeling of the patient.”
Dodson recommends reducing the stigma in healthcare by gently educating, using the term “use” instead of “abuse.”
“You have to change your language,” she notes. “If you go into a room carrying a negative opinion with you or thinking they’re a ‘junkie’ — and it is easy in human nature to have that happen — it can hinder your ability to care for this patient well.”
Creating Opportunities
Providing high-quality care for these patients brought an opportunity for AdventHealth. So far, it has been more successful than they imagined.
To specifically help people with opioid use disorder, they secured grant funds and worked with the local sheriff’s office to create the AdventHealth Hope & Healing Center, a place where patients can “access transformative treatment for opioid addiction. With the help of local, state, and now federal funding, the Hope & Healing Center offers a 30-day inpatient program as well as intensive outpatient treatment, including individual and group counseling, substance-related and recovery-focused education, reflection and spiritual healing groups, and career and housing assistance. This latest funding will enable AdventHealth to continue offering treatment to anyone who needs it, regardless of socioeconomic status or if they have insurance.”1
The center, which opened in 2021, has since served approximately 180 people, and the local community “has seen a decline in opioid overdoses and deaths.” Seminole County Sheriff Dennis Lemma reported a “25% decrease in overdoses and 39% decrease in overdose deaths” in the county.1
Since opening the center, “where we are now is really exciting,” Dodson says. “Changing processes for the whole hospital system — all different processes that didn’t exist three years ago — to see the growth is very rewarding.”
Dodson and Burba agree the real reward is working with this special population of patients and joining them on their journey, as tough as it may be at times.
“Seeing the resilience as people get up and try again, or do something different this time, especially when they are successful, — it is beautiful,” Dodson says. “Adjusting expectations is really important, because it’s a lifelong journey for most people. Case managers shouldn’t get discouraged when these patients relapse. They need a passion for these people, to learn their story, which almost always includes trauma of some kind. We’re all just here to help them on this journey.”
REFERENCE
- AdventHealth. U.S. Rep. Murphy secures $400,000 appropriation for AdventHealth’s opioid treatment center. May 3, 2022.
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