By Jeni Miller
Case managers make a difference in the lives of their patients, even when patients are only in the hospital briefly. This is especially true when a patient is undergoing a life-changing or traumatic event, like limb amputation.
According to the Amputee Coalition, most amputations are due to vascular diseases like diabetes, followed closely by trauma and, less frequently, cancer. More than 2 million people in the United States are living with limb loss, with approximately 185,000 amputations occurring each year. The likelihood of a hospital case manager encountering these patients is quite high.
“Although these patients typically have other health issues, they are often in and out of the hospital within three to 10 days,” says Ryan Butler, MS, CPO, clinical director at Nextremity Prosthetic Design LLC. “The case manager will only see them for about a week and then they are discharged.”
During that time, explains Butler, the case manager plays a big role in helping to stabilize, plan where to send the patient next, and what resources are needed. Metropolitan areas usually have more resources for the patient while rural settings may have fewer options available. Connecting with the community and compiling a comprehensive resource portfolio for amputations can make a significant difference for the patient.
But even more importantly, case managers can help guide the patient on what to expect during recovery and after. In some cases, they might be the only person who can help a vulnerable patient find help for a successful and less traumatic experience.
“One problem is that patients can go through the amputation and yet not have a lot of information about the process and what happens next,” Butler notes. “Understandably, the surgeons are concerned with the surgery, but not typically as much about prosthetics. Knowing what to expect in the first eight weeks is crucial.”
After surgery, it is common for surgeons to place a post-op protector on a patient’s limb, but some surgeons do not. For this reason, case managers should begin the process of connecting the patient with a prosthetic provider as early as possible, or even call a prosthetic provider to meet with the patient before surgery. However, case managers should look at the big picture to prevent miscommunication throughout the process.
“Some groups do fantastic,” Butler explains. “A team mentality is so important, especially because there is often a big team at work for amputations. With so many people involved, communication may be OK, but not great. Sometimes, there is no one overseeing the whole process, and the patient unfortunately ends up with two providers of prosthetics due to miscommunication — or no provider at all.”
When connecting the patient with a provider, Butler recommends case managers seek a prosthetic provider that consults more with the patient and takes the time to get to know him or her.
“Since the patient is often only in the hospital for a week, that’s just the beginning of their journey,” Butler says. “In an ideal world, prosthetic providers would work side by side with case managers to help with some of those initial conversations. Because of the nature of building a prosthesis, our visits are not just 15 minutes long, but often are a couple of hours because we get to know the patients quite well.”
According to a survey from the Amputee Coalition of America, nearly 30% of amputees reported experiencing depression, especially if the amputation happened because of trauma. Younger people were more likely to experience depression than those aged 65 years and older.
Butler recommends connecting patients with the Amputee Coalition’s peer visitor program to help amputees work through their grief.
“When you lose a limb, it’s like losing a family member. It can be quite challenging,” he says. “Talking with someone who has been there before — and having a case manager who is looking out for the patient’s psychosocial well-being — can help. Taking care of a patient is much more important than just replacing a limb.”
Part of the patient’s mental health status also can be related to pain. While there is pain involved in the surgery and recovery process, the prosthetic device itself should not cause pain.
“The world of prosthetics is constantly changing, but the more modern prosthetic devices we make should not be painful or uncomfortable to walk with,” Butler notes. “Years ago, people were putting up with a lot more. These days, if it’s painful, something is wrong.”
Perhaps the most significant area where case managers can make a difference for their amputee patients is mental health, which typically gets the least attention. However, it is important to remember that “often, the patient population that got into this situation is due to poor choices like not monitoring blood sugar or ulcers, not eating right, and then an amputation results,” Butler notes.
This problem, Butler explains, combined with the biggest measure of success — patient attitude — means case managers can be “significantly helpful in guiding a patient in the right direction with wellness and attitude.”
It is a “tricky problem to address,” he says. But “case managers may be the first and best to bring up this conversation since they are well-versed in asking the right questions, and even the tough questions.”
Patients also might ask case managers: “When will I walk again? How well will I walk again?”
“Case managers should know the answers to these questions,” Butler explains. “For the patient, it often depends on how well they were walking prior to surgery, so the case manager can share that they might expect to return to that point. If they were walking with a walker, they will probably still use a walker following their surgery.”
Butler notes below-the-knee amputations typically result in better outcomes than above-the-knee, but case managers should be prepared to share with their patients the more realistic expectation that it will take six weeks to three months before they will walk comfortably with a prosthesis. Even then, their success can depend on their fitness level.
Case managers should see the amputation patient as a whole person, caring for every aspect of their well-being and helping him or her achieve the best possible quality of life.