EXECUTIVE SUMMARY

Case managers faced many challenges in helping patients during the COVID-19 crisis, including connecting homeless patients to care and resources.

  • Case managers can follow up via phone to help keep patients healthy and connected to care.
  • Rush University Medical Center created a community command center in one part of Chicago for COVID-19 patients who do not need hospitalization.
  • Nurse case managers and others need to practice self-care to help them through the crisis and deal with residual feelings and concerns after the pandemic.

Case managers continue to work with their chronically ill patients throughout the stay-at-home orders, often through telemedicine or by taking more precautions for in-person encounters, such as wearing personal protective equipment (PPE).

The challenges case managers experience with helping homeless patients access care and resources became much more challenging in the face of the pandemic.

“What do we do with homeless COVID patients?” asks Mary McLaughlin Davis, DNP, ACNS-BC, NEA-BC, CCM, senior director of care management nursing at Cleveland Clinic.

“We identified this would be a problem, before it became a problem,” Davis says. “We are working with city and county governments to develop a plan with funding from all of these resources to discharge patients to a hotel as their home for the 14 days of isolation.”

Follow-up phone visits also are part of the plan to keep homeless patients healthy. In some places, homeless shelters are kicking out people because they do not want to become COVID-19 hotspots, says Robyn Golden, LCSW, associate vice president of population health and aging in the department of social work and community health at Rush University Medical Center in Chicago.

“Rush created a shelter in the west side of Chicago just for people who have COVID-19, but don’t need to be hospitalized,” Golden says.

Because of the pandemic, there are a number of people who are newly homeless. Some in this population will need help with food and shelter for the long term, she adds.

“Rush is probably seeing around 25% of people in Illinois with COVID-19,” Golden says. “It’s been unbelievable in terms of how much we’re doing to anticipate [problems] and get ready for all sorts of things.”

The biggest gap that community case managers are seeing during the pandemic involves food, says Bonnie Ewald, MA, associate director of the Center for Health and Social Care Integration at Rush University Medical Center.

“Even if people were enrolled in SNAP [Supplemental Nutrition Assistance Program] recently or had an increase in SNAP benefits, we find they need food quicker,” Ewald says. “We have a Rush program [that covers meal boxes for patients who can’t afford it, and we have employees deliver that food.”

The focus on food resources is in addition to traditional care and case management post-discharge, she notes.

“Those kinds of things are what our team is helping with,” Ewald says. “There have been a lot of renewed and expanded food initiatives.”

Rush has created a community command center that identifies the most pressing needs, how the team can fill them, and working with the city, she explains.

Rush’s department of social work and community health provides phone support to patients after discharge, says Elizabeth Cummings, MSW, LCSW, manager of transitional care in the department of social work and community health. “Everything begins after someone goes home or leaves the clinic space,” she adds.

Since the department always provided phone support, it was a fairly smooth transition when operations changed because of the pandemic, Cummings notes.

“We can care for patients the way we always have, and it’s been nice to get in touch with patients,” she adds. “It’s even easier now because patients have to stay home, and they’re looking forward to our calls because we’re providing some support for them to focus on their care goals.”

Healthcare Staff Face More Stress, Trauma

Social workers provide one-on-one support to staff to address all of their emotional needs during the pandemic, Ewald notes. “We’re calling people who test positive at Rush or who are negative, but have other psychosocial issues that come up.”

Case managers and other staff have been dealing with patients experiencing traumatic losses at a time when they are unable to provide hands-on support, Golden says.

“I heard a story of a woman whose husband died of COVID-19, and he was alone at the hospital. Now, she’s home with COVID-19,” she laments. “I can’t imagine these aspects of trauma our staff have never before experienced. I’m so worried they are burning out and becoming exhausted.”

The psychosocial medical issues are within social worker case managers’ wheelhouse, but they can be overwhelming — especially when they are helping staff as well as patients.

“It’s important for nurses, managers, and all leaders to understand that, despite the barriers and challenges we currently face, empowering direct care nurses is essential to validating the meaning of their work,” says Caryl Goodyear, PhD, RN, NEA-BC, CCRN-K, practice excellence programs manager with the American Association of Critical-Care Nurses. “These nurses are smart, intelligent, resourceful, and very creative. They know all too well what needs fixing, and have a lot of ideas about how to do that.”

Case managers, social workers, and other healthcare workers need to support one another during these stressful times. A collaborative, supportive atmosphere can help people cope.

“What has been wonderful is how we come together as an institution from a medical center perspective,” Cummings says. “We rally around and try to create a space for people to manage all of this uncertainty.” This has been critical to helping staff and teams to support one another, she adds.

Case managers, social workers, and other healthcare professionals will need to engage in self-care so they can continue to be a support system to patients who are in crisis during the pandemic and an anticipated long recovery period.

“People are grappling with the effects of isolation, including boredom, loneliness, and mental health issues,” Ewald says.

Healthcare workers are facing decision fatigue and stressors that they likely have never encountered before, says Laurie Chaikind McNulty, LCSW-C, wellness advisor in the Office of Intramural Training and Education at the National Institutes of Health. McNulty spoke at an April 14 webinar about managing stress during the COVID-19 pandemic, available online at: https://videocast.nih.gov/summary.asp?live=36371&bhcp=1.

Stress occurs when people experience a change in their physiological homeostasis or psychological well-being, McNulty says. Common stressors during the pandemic include uncertainty, scarcity of PPE, balancing work and family, financial issues, job security, unpredictability, helplessness, isolation, decision fatigue, information overload, disappointments and cancellations, and expectations from supervisors. People often have no control over these stressors, but they can ask for help when they need it and, also, allow themselves to fall short of their own expectations.

“We can say, ‘This is something I’m struggling with and I might need a little extra help with it,’” McNulty suggests.

Also, as areas ease into the next phase of the pandemic and reopen public life, healthcare professionals need to put away expectations that they easily can bounce back to their pre-pandemic selves. “Bouncing back requires a lot of things,” McNulty says. “It requires reaching out to people and collaborating.”

It also requires resilience, which individuals can build within themselves through focusing on these six areas:

  • Vision: Create a purpose and goals.
  • Composure: Regulate emotions, watch out for interpretation bias, stay calm and in control.
  • Reasoning: Engage in problem-solving, become resourceful, anticipate, and plan.
  • Health: Practice good nutrition, sleep better, and exercise.
  • Tenacity: Be persistent, set realistic optimism, and be open to bouncing back.
  • Collaboration: Access support networks, look at social context, and manage perceptions.

Resilience is important for case managers when they help patients cope with anxiety and loneliness. They should remember that there are some circumstances they cannot control and to focus on more of the things they can.

For instance, isolation and its effect on elderly patients is challenging, and case managers will not be able to solve this problem of the pandemic. But there are some tactics that healthcare institutions and individual healthcare workers can employ to at least help people with their loneliness. Wellness visits to people in some of the poorest communities served by Rush have shown that people are anxious and afraid to walk outside, Golden says.

“There is such an epidemic of isolation at this point,” Golden adds. “It’s a troublesome time. Suicide rates of older adults are going up and are predicted to go up.”

One way to help patients cope with isolation and loneliness is through using teleconferencing apps so they can see and talk with healthcare providers, family, and friends.

Case managers can help patients use these apps by providing them simple instructions and back-up technical support for virtual events.

“Our whole team has translated all of those health lectures and self-management activities to happening virtually, which is not an easy task,” Golden says.