Include DM when you work with patients

Comorbidities can negatively affect recovery

Even if you're not a designated disease management case manager, you can help your clients manage their chronic diseases, according to Carole M. Stolte-Upman, RN, MA, CCM, CRC, CDMS, CPC, director of Chesapeake Disability Management Inc., a disability case management company in Towson, MD.

"It's all a part of the case management concept of taking care of the entire person and not just the broken leg. Case managers can fill the role of being the eyes and ears of a disease management program when they are on-site. They can augment the telephonic component of disease case management," she says.

Case managers are in an excellent position to identify patients who have underlying comorbidities that can impede their recovery and to educate these patients about their condition and how to manage it, Stolte-Upman adds.

"Because one question leads to another question, case managers can sometimes stem the course of the disease by picking up cues and asking the next question that would lead to better management of that disease," she says.

For instance, if an organization has a cardiac disease management program and is following an individual by telephone, an on-site assessment may be needed. Case managers are in an excellent position to provide that kind of information, she adds.

At Stolte-Upman's organization, 95% of the case management practice is workers' compensation. Although the case managers are not specifically targeting chronic diseases, they often work disease management education into their case management initiatives, she reports.

"When we manage long-term disability clients, we are always attuned to the fact that there may be underlying diseases that negatively impact the course of care," Stolte-Upman says.

For instance, in the case of an injured worker, an underlying problem such as diabetes can impact the healing.

"They often have a lack of understanding of their disease. They have failed to go to their primary care physician for regular checkups and haven't complied with the plan of care. Our case managers are out there front-and-center and are in a good position to offer the education component to help the worker keep the chronic disease under control," Stolte-Upman says.

She once handled the care for a patient with hypertension who passed out and fell off a roof.

The client said he had been told he had "bad blood," but added that he would know if he really had a problem and he knew very little about his disease.

"This is another example of how on-site case managers can collaborate with disease managers by identifying the level of knowledge, helping the patient avoid potential secondary complications, and getting the patient into an early treatment program," Stolte-Upman adds.

Case managers who encounter people with chronic diseases should make sure that the individual is hooked up with the appropriate medical care.

If the patient isn't covered by insurance, case managers can plug them into free or sliding-scale management programs in clinics or can work with the primary care physician to put them into a medication program or drug study program, she adds.

Stolte-Upman estimates that at least half of the workers' compensation patients she manages have some kind of underlying comorbidity. Arthritis, lupus, hypertension, diabetes, and cardiovascular disease are among the most common conditions.

"We have always seen a lot of things coexisting with industrial injuries. Our aging work force has had an opportunity to develop other health care issues, and we have an opportunity to be proactive in addressing these," she adds.

Case managers often encounter the presence of drug and alcohol problems in their clients and can take that opportunity to refer the client to a disease management program, Stolte-Upman says.

Case managers should talk with their patients with chronic disease to determine the barriers to managing the diseases.

"It may be fear, lack of knowledge, lack of financial resources, and lack of understanding. It's amazing how many people are not sophisticated health care consumers and have no idea of what the appropriate treatment is for their disease," Stolte-Upman reports.

When she assesses a new client, she looks for underlying factors that will prevent a good outcome in addition to information relevant to his or her industrial injury.

"We find out what the barriers to care are and identify the kind of care that would be accepted by the patient," Stolte-Upman says.

Case managers should always be sensitive to cultural diversity when they treat patients and have an understanding of the issues that can be an incentive or disincentive for them to follow the plan of care, depending on their cultural background.

"The nurse case manager holds the key to finding the way to address the issue in a way that the patient is comfortable with," she says.

For instance, many cultures use homeopathic and home care remedies, some of which could interfere with their treatment.

In these instances, the case manager needs to be supportive and nonjudgmental while concurrently demonstrating respect for unfamiliar belief systems, Stolte-Upman says.

"We carefully build on that respectful relationship to encourage compliance with treatment plans that will render positive outcomes," she adds.