Case studies show advocacy in action
Sometimes little things have great impact
The Standards of Practice developed by the Case Management Society of America (CMSA) in Little Rock, AR, state clearly that case managers must advocate for their patients. However, it's not always clear what advocacy means. One case manager-turned-attorney says true advocacy often is found in the details. (For more on advocacy in the managed care era, see story, p. 113.)
"Sometimes, it's the little last minute phone calls that make the most difference to your clients," says Lynn S. Muller, RN, JD, CDMS, CCM, a partner with Muller & Muller in Bergenfield, NJ. "Those small details you take care of are doing your clients the most good, and you aren't giving yourselves enough credit for it," she told case managers attending the recent CMSA conference in Reno, NV.
"When I used to call fire departments to let them know there was a disabled person coming home to their community, they often treated me like I had 12 heads," she says. "Then, after a while, I'd make that same call, and the fire department would simply agree to add my client to `the list.' Great! There's a list!"
To advocate for patients effectively, case managers must consider all aspects of their patients' lives, Muller says. "Will your disabled patient be using public transportation? Is there an appropriately equipped bus in his area? If not, call the local taxi company. Tell them if they get a call from your client, pull up to the house, and see his wheelchair, they don't have to panic. Explain that he knows how to transfer, and all the driver has to do is fold the wheelchair and put it in the trunk."
Case study
Muller had a recent elderly client who, at the age of 80, had successful bypass surgery. Because she lived alone, she was transferred to a nursing home as a transition to home care. During her nursing home admission, she contracted an infection and returned to acute care. When the infection was cleared, she was admitted to a second nursing home.
During the second nursing home admission, Muller, who had the patient's power of attorney, was on hand to sign all the documents for her. "Included in the documents was a 10-page living will that I had drafted for her. I watched as it was properly attached to her chart."
Keep your antenna up
Two days later, she visited her client and noticed a big orange "Do Not Resuscitate" (DNR) sticker on the chart. Muller quickly confirmed that the 10-page living will was still attached to the chart. "I got hold of the head nurse, who told me that my client had signed a DNR form."
The head nurse told Muller the nursing home case manager had obtained her client's signature on the DNR form. In fact, the nursing home case manager, in an attempt to simplify the form's content for Muller's client, who is hard of hearing, said, "Oh honey, you don't want them sticking that tube down you, do you? I looked at the head nurse, and told her, 'Why don't you pick up the phone and tell the surgeon why his successful bypass patient is a no code?' As a case manager, you must always keep your antenna up and maintain an ongoing dialogue with your clients and your clients' providers," Muller says. "The nursing home case manager obtained that signature without my client understanding what it was. That's not advocacy.
"I challenge you to walk the high road. Always pause and think things through before making decisions that may not be in the best interest of your clients. If the insurance adjuster calls and tells you something that doesn't seem quite right, tell the adjuster you'll call back later," Muller suggests. "Not all questions require an immediate response. Take your time and always think things through."
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