EXECUTIVE SUMMARY
Case managers can help their elderly patients better handle the medical and psychosocial issues related to the coronavirus pandemic through following specific educational and support techniques.
- One technique is to reinforce symptom management and teach patients to seek help when they need it.
- Case managers should assess patient’s needs and desires, and work toward shared decision-making.
- Before suggesting telehealth options to patients, case managers should learn what these options are and how to use them.
The COVID-19 pandemic makes care coordination and case management more difficult for a variety of reasons. For instance, finding community resources for struggling senior patients is difficult in areas where organizations have closed operations or restricted access to services. Also, senior adults face more loneliness and emotional health challenges. They have lost access to many of their traditional social support networks because of physical distancing during the pandemic.
Plus, people are living with uncertainty. They do not know when they can see their families again safely. They fear visiting hospitals, emergency departments (EDs), and clinics because of the risk of SARS-CoV-2 infection. Most of all, older adults fear COVID-19 and what it might do to their health.
“For our elderly population and COVID, the biggest thing is the unknown,” says Sheila Haynes-Baisden, BSN, CCM, transitional care coordinator of the ED at the Cleveland Clinic. “We really don’t know the effect that COVID is going to have on the body once somebody is exposed to it. Our patients with pre-existing conditions are at a greater risk.”
Haynes-Baisden and other healthcare professionals offer these suggestions on how case managers can help older patients manage their comorbidities and maintain their physical and emotional health during the COVID-19 pandemic:
• Reinforce symptom management and seeking help when needed. Pre-COVID-19, case managers used a variety of tools and skills to help patients manage their comorbid conditions and avoid ED visits and hospitalizations. The pandemic changed case management strategies by making it more challenging for patients to obtain elective surgeries, visit physical therapists, and see their primary care providers and clinics.
On top of that, many older people were afraid to visit the ED if they experienced an exacerbation of their symptoms, says Saket Saxena, MD, a geriatrician at the Cleveland Clinic.
“What we have seen with older folks who need some sort of urgent/emergent care or assessment is they have been avoiding coming to the emergency department,” he says. “Whether they were avoiding for their own safety or concerns from family members caring for them, this trend became prominent in the beginning of the epidemic in March, April, and the early part of May.”
EDs saw decreases in patient visits, but an increase in patients calling them to ask for advice, he adds.
“Cardiologists and neurologists have come to a similar conclusion that patients were not coming to the emergency department despite their health concerns. This was especially true for older patients,” Saxena says.
Entering a hospital is a frightening experience, especially when patients must enter alone, as has happened during the pandemic when hospitals and EDs stopped allowing family members to accompany the patient into the facility, notes Mary D. Naylor, PhD, RN, FAAN, Marian S. Ware professor in gerontology and director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing.
“Family members are leaving patients off at the emergency room door because of changes in policies,” Naylor says. “It’s a frightening experience to go into a health system and not have your social support system.”
• Carefully assess patients’ issues and desires. “My biggest advice is to get to know the individual nuances of the people you work with; they are people first, patients second,” says Jean Scholz Mellum, PhD, RN, NEA-BC, assistant professor at Capital University in Columbus, OH. “Case managers need to take time to assess the people they’re working with, get to know their individual desires, socioeconomic status, and know the resources that might be available to them because of who they are and their unique circumstances. Once you get to know that person and have a thorough assessment, you can develop a good plan of care for that individual. It works best when you co-create that plan of care.”
The case management role is to help patients become successful in managing their own healthcare trajectory. Shared decision-making is essential for success, she adds.
“I’ve had a lot of experiences where well-minded healthcare providers and the children of older adults want to be in control. They want to tell their patients what to do, and that doesn’t work well for the individual,” Scholz Mellum says.
• Ask about loneliness, particularly related to the pandemic. Case managers should assess patients’ loneliness during the psychosocial assessment, Scholz Mellum suggests.
“It’s very important to think about that,” she explains. “Maybe the loneliness is a reason to move into a senior facility, where they have people their age around them.”
During the pandemic, many older adults may feel increasingly lonely if their families and friends cannot visit them. Also, they might not be able to attend church services and community group outings and activities as they did before COVID-19.
“It’s up to the case manager to care enough to ask questions to figure out whether a patient is lonely and to put that person into a situation that is not as lonely,” Scholz Mellum says.
For example, if an older patient lives alone, the case manager might suggest the patient’s family members call the person on a rotation basis. Each day, one of the patient’s children or other family members can call the person to check in on him or her, she says.
“It’s also good to have someone who is local, like a neighbor, be a backup,” she adds. “For instance, I was that backup for my neighbors’ children, who cared for their elderly mother from afar.”
Scholz Mellum had keys to the neighbor’s house. When one of the neighbor’s children could not reach the mother by phone, they asked Scholz Mellum to go over and check on her.
“It worked,” she says. “That kind of thing also goes on in churches, senior centers, and other places. Care coordinators are perfect people to suggest those kinds of things.”
The pandemic has made this more urgent. “COVID-19 does accentuate the loneliness,” Scholz Mellum says. “A phone call is easy. Video chats are challenging for some older adults, but with phone calls, some people don’t know what to talk about with the older adults. That’s where a care coordinator can give suggestions.”
Case managers can suggest family members start phone conversations by asking questions, such as:
- What was your favorite vacation?
- Do you have an outfit you like to wear?
- What kind of music do you enjoy?
- Say, “Tell me a story about how you met your spouse.”
• Learn the best ways to use telehealth services. “One tool being deployed right now is telehealth, and it’s had a very dramatic increase for all case management services,” Naylor says. “We’ve come a tremendously long way in terms of our capacity to rely on telehealth. Case managers need to know how to use it and to make sure the intended recipients of care have the tools they need, including broadband and technology.”
Patients also need to know how to use technology. For instance, if they are asked to report their symptoms daily through an electronic diary or messaging, the case manager will need to show them how.
“Case managers also need to understand how to use these tools in a culturally sensitive way,” Naylor says. “Case managers need to be a big part of that learning; they need to know how to use tools and how to teach patients and family caregivers how to use these different resources.”
• Teach patients to watch for signs of COVID-19. “Here we are in a pandemic, where we’re daily growing in our knowledge of new symptoms to pay attention to,” Naylor says.
“We don’t know enough about the extent and length of symptoms and the impact it will have, over time, on patients and family caregivers,” says Karen B. Hirschman, PhD, MSW, term chair of the NewCourtland Center for Transition and Health and research associate professor at the University of Pennsylvania School of Nursing.
Every healthcare provider, including case managers, needs to learn as much as possible about COVID-19 symptoms, disease progression, and infection prevention. “We need to help patients know about valuable resources,” Naylor says. “This is a crazy time for information. Some is evidence-based, science-based, and some is not. We should help people understand which are our trusted resources for new knowledge that is evolving.”
For example, the Centers for Disease Control and Prevention (CDC) published a list of symptoms that are continually updated. (The list is available at: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html.)
The CDC names the usual symptoms of fever, chills, cough, shortness of breath, fatigue, muscle aches, headache, and congestion. But it also lists lesser-known symptoms such as a new loss of taste or smell, sore throat, nausea or vomiting, and diarrhea. There are emergency warning signs, such as trouble breathing, persistent chest pain or pressure, new confusion, inability to stay awake, and bluish lips or face.
