Payers, including the federal government, are beginning to recognize that healthcare providers can succeed with keeping patients healthy only to the extent that patients are willing collaborators in their own care.

If patients refuse medical help when it is clearly needed or when they fail to take their medications and see their doctors, their health problems will continue and medical costs will rise.

One solution developed by a physician with a master’s-level business degree and a social worker is negotiation between case managers and patients. It works best when case managers receive negotiation strategies and training that are similar to what are used in business settings.

Case managers will need negotiation tools prior to engaging with a potentially resistant patient, says Lee Lindquist, MD, MPH, MBA, chief of geriatrics at Northwestern Medicine in Chicago.

“People want to go home from the hospital and stay in their own home as long as possible, and it often times falls on the case manager/social worker to make it happen,” Lindquist says.

Many patients are too frail or too sick after hospitalization to manage on their own, but they still might receive home healthcare and other home medical services. This can jeopardize their ability to maintain good health and stay out of the hospital. The key challenge for case managers is to convince patients to accept the services.

While Lindquist was earning her MBA, it occurred to her that a lot of the information she was learning about business could be taught to healthcare professionals to help them become more effective in reducing readmissions and working with patients, she says.

From this knowledge, she helped develop training programs for case managers about negotiating with patients in refusal-of-care situations.

“We teach courses to case managers about the main reasons people might choose to not receive medical services, and then we teach tactics that they teach at most business schools,” Lindquist says.

Successful negotiation begins with understanding the other side’s perspective.

“What we see is people are very reluctant for their independence to be taken away,” says Annie Seltzer, LCSW, CSW-G, a social worker specializing in the geriatrics clinic at Northwestern Medicine.

“Typically, a social worker or case manager will go into the patient’s room upon admission and do a full psychosocial assessment in which they gather data about the patient’s living situations, social support, activities of daily living, and what the patient is able to do independently and what the patient needs help with to get a bigger picture of the patient’s current functioning,” Seltzer says. “From there, they can make recommendations of when the patient is ready to go home.”

Hospital providers might recommend the patient be transitioned to a post-acute care facility before returning home. But in Seltzer’s experience, patients being discharged from the hospital mostly prefer not to go to a skilled nursing facility or post-acute rehabilitation center as they fully recover, she says.

“We are lucky in Chicago because we have a lot of services for people who want to stay home,” Seltzer says.

Home health services can sustain many patients, but convincing patients to accept even this level of care can be a challenge. That is where negotiation tactics can be employed.

“It’s the idea they are giving up their independence and need to accept help,” Seltzer explains. “The idea of having someone come in and do our cooking and cleaning sounds nice to us, but for people in their 70s and 80s, it sounds like someone is taking away their autonomy.”

The first step in negotiation is to ascertain whether the patient is capable of making a sound decision. Some patients have dementia and could manage at home with help, but they might experience difficulty participating in discussions that require a higher level of cognitive awareness, Seltzer and Lindquist say.

“We need to make sure the patient is someone who is able to cognitively make these decisions and remember the conversation,” Seltzer says.

Once the case manager is confident the patient is capable of his or her own decision-making, the next step is to ensure the patient feels supported and understands how safety is a top priority of healthcare providers.

“I almost always say to patients in our clinic setting that it’s everyone’s goal to make sure the patient can stay as independent as possible for as long as possible, while making sure their safety is not being compromised,” Seltzer says.

“We want to make sure they feel supported and are treated well and that they’re also getting the services they may not think they need,” Lindquist adds. “Most people, in their own minds, feel younger than their bodies, and when they are hospitalized they become weak.”

So they want to return home and are not convinced they still need help.

“We teach a course that talks about the main reasons people choose not to do home health services and why they resist these,” she says. “Then we teach tactics to case managers and social workers that are like the tactics they teach at most business schools.”

Participants in the negotiations skills classes also role-play to develop confidence in their ability to negotiate successfully with patients.

One negotiation tactic is to use empathy.

“Patients don’t like the idea of losing independence, so we talk about how no one is ever truly independent — we’re intra-dependent,” Lindquist says.

For example, senior people often have helped other family members and friends — altruism that gives them as much joy as they give to others, Lindquist says.

A case manager can explain how the patient’s acceptance of help from home health providers is the same thing.

“We help seniors understand that by accepting someone into their home, they’re giving the person an opportunity to experience joy,” she explains. “This type of reframing — spin tactic — gets past their resistance.”

Reframing is a psychological strategy to change the way one looks at a situation in order to shift an emotional reaction or state. It can be used by therapists and others to build resilience and help someone go from feeling negative about a circumstance beyond their control to viewing the same circumstance from a more positive perspective. (More information is available at:

Focusing on the joy of helping someone gives the patient a new way to view his or her home health services.

“We’re reframing it so it’s not about the senior as much as about the people around them,” Lindquist says. “We always teach case managers to be more positive: Instead of ‘You need help; you’re having problems in your home,’ it’s a more positive message of ‘If you accept someone in your home, you’ll be helping them.’”

Before engaging in negotiation with patients, case managers will need to prepare. Practicing negotiating tactics can help, and this is where role-playing is helpful.

For instance, case managers could practice how they would handle patient resistance in specific, real-world cases. Through practice, they grow more comfortable with negotiating tactics and with working with patients to improve their engagement with healthcare services.

“It’s collaborative with patients,” Seltzer says. “This is a good way to respect patients’ autonomy and have them participate in their own decision-making.”