EXECUTIVE SUMMARY

Poorly developed communication strategies can undermine case management efforts to inform and train patients.

• One strategy to improve communication and conversations with patients is to ask the patient more clarifying questions to identify the overall goal.

• Case managers can help families find resolutions that bring peace to stressful situations.

• Case managers can advocate for patients.


Case managers play an important role in providing information to patients and caregivers. They also provide training and follow-up with patients during transitions following a health crisis. They could perform all of their responsibilities very well and still miss the mark that leads to optimal outcomes.

Why? One answer: underdeveloped communication strategies.

“If you have an opportunity as a case manager at any stage to have a comprehensive conversation with a patient and the family, it’s always the ideal,” says Eboni Green, RN, PhD, co-founder of Caregiver Support Services in Omaha, NE.

“Sometimes you collect data in bits and pieces,” Green says.

For a holistic picture of what’s going on, ask the patient more clarifying questions to identify the overall goal.

“We know very few people actually communicate their decisions,” Green says. “If you have a good idea of what the goals are for the caregiver and patient, then you have the opportunity to advocate for what you feel like will work, what you know their wishes are, resulting in fewer regrets from the family’s perspective.”

Case managers are in a good position to advocate for patients, but they need information about what the patient wants — as well as what health providers want for the patient. The way to find out what they want is to develop a rapport with patients and listen to what they say they need.

This is especially important when patients have not spelled out their decisions and plans in advance directives.

“We have the ability as case managers to explain to our client the variety of options that are available, which can be overwhelming for families,” Green explains. “We give them a couple of options to assess their situation.”

Case managers with conversational skills can help families find resolutions that bring peace to stressful situations.

For example, Green experienced the difference communication makes when her husband and she were caregivers for his stepfather. When the stepfather was hospitalized after a terminal diagnosis, Green and her husband knew that he wanted to be home because they had spent time talking with him. But his other adult children were unaware of his wishes.

“For him to articulate what his wishes were, we had to have a family meeting at the hospital,” Green says.

“So you have varying views from my mother-in-law — his wife of 40-plus years — and four children, who were involved in the situation,” Green explains. “The biological children felt they should be making the decisions, but my father-in-law wanted my husband to oversee his care.”

To make this difficult family meeting work, they had a nurse practitioner case manager facilitate a conversation with all family members. The case manager helped people understand that the patriarch wanted Green’s husband to make decisions and that he didn’t want any additional treatment to prolong his life.

There were compromises: Green’s father-in-law wanted to die at home. Hospice workers could have visited his home and helped provide care, but his wife was not emotionally able to handle that decision. So he went to a long-term care setting for end-of-life services.

“We were able to assist my father-in-law with the outcomes he wanted, and there wasn’t all of the family drama,” she says. “We worked with the case manager to set expectations and to work through that process to make sure things were done the way he wanted them done.”

The experience led to Green helping to create a conversational guide, called RightConversations. It features several downloadable resources and videos to help families hold these difficult conversations. (The guide is available at: http://bit.ly/2KapBGz.)

“It is a comprehensive conversation guide,” she says. (See related story in this issue on how to plan the conversation.)

The guide offers tips on improving a family’s understanding of the loved one’s behavior and illness. One tip about involving siblings suggests:

• involve the right people in the conversation with the loved one from the beginning;

• help siblings who live at a distance truly understand the magnitude of the situation;

• understand how the loved one may share different information with different members of the family, creating information gaps among siblings; these differences should be addressed quickly to keep lines of communication open;

• be aware of self-interest, setting it aside and focusing on the loved one’s well-being to avoid distorting the decision-making process.

Case managers also can work on developing conversational skills for communicating with other healthcare professionals.

“In the best-case scenario, you have an opportunity, if you have adequate information, to communicate what the overall goal is for the family,” Green says.