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Community case managers help navigate health care
Outcome: more effective care plans
Faced with a complex, difficult-to-negotiate health care system, multiple providers, and myriad treatment options, many health care consumers are looking for somewhere to turn, and that means opportunities for case managers, says Catherine M. Mullahy, RN, BS, CRRN, CCM.
"Consumers pay for tutors for their children. They pay for legal advice and financial advice," says Mullahy, president and founder of Mullahy & Associates, a case management training and consulting company. "Why wouldn't they be willing to pay for an independent professional case manager to be their advocate as they visit the doctor, to help them understand their treatment options and their medication and to help sort out the confusion?" she asks. Mullahy frequently hears case managers say they are discouraged by increasing paperwork that takes them away from direct patient contact. But while they are not satisfied with their jobs, they don't want to leave the field.
Community-based case management gives independent case managers the satisfaction of developing long-term relationships with their patients and allows them to balance their home life and their professional life, she says.
Getting back to the patients
The process of case management works so well, but you can't do effective case management when you have a caseload of 100 patients, says Mullahy. Case management is so individualized and involves so many components, she says. "The best way is to put case managers in the community," Mullahy says. "When you can see a person in his own environment and develop a personal relationship with him, you can be a better advocate."
Her words are echoed by Susan Moore, RN, PN, a Chicago-based case manager who specializes in oncology and contracts with cancer patients and their families to support them through diagnosis, treatment, and survivorship. "Meeting with people helps develop a closer relationship," Moore says. "The people I see personally think of me as a nurse case manager, advocate, and a friend. Those I work with by telephone see me as a nurse case manager and a resource, but the personal contact is lacking."
When Mullahy speaks at health care seminars and forums, she asks the nurses if they have patients who are readmitted to the hospital or visit the emergency department repeatedly because of something that happens after discharge.
Regardless of the setting in which the nurses work, the answer is always "yes."
Discharge plan problems rampant
Patients are getting out of the hospital quicker and sicker, but hospital discharge planners don't have the time to make sure that the discharge plan that looks great on paper really works, Mullahy says.
"Sometimes the patients are being treated by multiple physicians and they don't know which practice to call when they have symptoms," she says. "They call and get voice mail and the problem isn't corrected, so they go to the hospital and are treated by yet another doctor."
Chronically ill or catastrophically ill patients may receive telephone calls from a case manager, a disease manager, a health coach, and a discharge planner, but they don't talk to each other and none of them know what's going on in the home or what issues or obstacles to adherence the patient may face.
"The health care system is broken," Mullahy says. "The process of case management is a wonderful process, and it's not broken. What is broken is where and how case managers are being used."
Mullahy recalls the words of a patient in the hospital coronary care unit where she started her nursing career. "I was telling him how he needed to make lifestyle changes, to pace himself better, and to consider another job," she says. "He said, 'You have no idea what my life is like,' and he was right. You can't possibly know what an individual's life is like and help him or her make lifestyle changes until you have a relationship with them."
Case managers can't determine whether their discharge plan will work unless they know what is going on in the home. Is it in a trailer park or the inner city? Is it crowded and dirty? All of those factors can affect the discharge plan and the patient's ability to adhere to the treatment plan, she says. "I remain convinced that the best way to do case management is on site," she says.
The on-site model
The model already is working with geriatric case managers who help manage the care of elderly patients whose children are living in other parts of the country, Mullahy says. Many geriatric case managers are social workers, but there are many elderly people with complex conditions who could benefit from the help of a nurse case manager, she adds.
You can't work with elderly Medicare patients over the telephone, Mullahy says. "You have to see them up close and personal to determine what is wrong," she says. Some have dementia. Some have personal problems. Many have hearing problems. "You can't work with them telephonically, and you can't expect them all to use a web site to obtain the answers to the questions they may have or get the reassurance they need," Mullahy says.
Some insurance companies are beginning to provide face-to-face interventions for their high-risk clients. For example, WellPoint locates community resource centers in areas where there is a large population of members in its publicly financed insurance programs to better serve its members by building a relationship, says Nancy Atkins, MSN, RNC, NP, vice president of state-sponsored business for WellPoint.
"We realized that we couldn't adequately serve members' complex medical and social needs with just a toll-free number," Atkins says. "With people whose needs are so complex and far-reaching, it takes a personal relationship to make a difference."
But the elderly and other publicly funded clients are not the only people who could benefit from an independent, community-based case manager, Mullahy adds. People who are catastrophically ill, people who are newly diagnosed with cancer, those with life-changing illnesses such as congestive heart failure or end-stage renal disease, parents of children with multiple handicaps or chronic illnesses all could benefit from someone who could help them understand their condition, evaluate treatment options, and help them comply with the treatment plan, she says.
"The goal would be to empower patients and families to become their own case managers," she says. "Some people may need only a few weeks of help until they understand what's going on. Others may need case management for several months."
In addition to patients and family members, sources of referrals for community-based case managers may be treating physicians, Mullahy points out. "As the trend toward giving physicians pay-for-performance incentives continues, some physicians are hiring case managers to help them improve the outcomes for complex patients," she says. "There is more recognition that complex patients need a different kind of intervention."
Sources of referrals could include physicians who have difficult-to-manage patients, financial advisors who work with trust funds on behalf of individuals who suffered birth injuries or life-altering injuries from accidents, employers that offer health savings accounts, or self-insured employer groups not large enough for a managed care case management program.
"There's a push toward consumer-driven health plans and consumers assuming control of their health care but the system we have is not one that works for the average person," Mullahy says. "Of equal concern, the system is difficult even for those of us who have worked in the midst of it for all our professional lives. Patients and their families need someone to advocate for them and to help them through the health care maze, and the community-based care managers can be that caring professional." (Editor's note: For more information, contact Mullahy at Mullahy & Associates, Huntingdon, NY. E-mail: email@example.com. Web: www.mullahyassociates.com.)