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When Gary Wolfe, RN, CCM, talks about how case managers in multiple venues should work together, he often quips: "Will the real case manager please stand up?"
It’s not unusual for patients with co-morbidities and chronic illnesses to have case managers from the hospital, insurance company, durable medical equipment company, home care agency, a large physician practice, and maybe even a disease management company all helping manage their care.
Not only is having multiple case managers on a single case stressful for the case managers, it’s particularly confusing to the consumer and to primary care providers, says Wolfe, a case manager in private practice in the San Francisco Bay area and editor-in-chief of Care Management journal.
Toni Cesta, PhD, RN, FAAN, tells of a cartoon that made the rounds a few years ago. It showed a bed-ridden patient with 10 people hovering around him, all of them labeled "Case Manager." "It’s an area of confusion for all of us, including the patients," says Cesta, director of case management at St. Vincent Hospital in New York City.
Conflicts even can occur between people who manage patient care and work for the same venue, says Alan Cudney, RN, MBA, MHS, CPHQ, CHE, an associate with Premier Inc. in Charlotte, NC, a health care alliance enterprise owned by more than 200 nonprofit hospitals and health systems. For example, he says, tension often exists between nurses and case managers in the hospital setting. "I know of one hospital — and there probably are more — where there was a case manager, a social worker, and clinical nurse specialists who did disease management, and a bedside nurse, all trying to manage care at the same time. This only leads to confusion and chaos," he adds.
And, then there are the physicians who just want to get all of these case managers out of their hair.
"In this country’s increasingly complex health care milieu, someone needs to be a coordinating linchpin to help the various services meet the needs of the physician and the patient," says Cudney. "I promote collaboration at every step of the way and encourage each party to be clear on what their responsibilities are."
Case managers should take a proactive role and pull the whole health care team together, adds Cesta. (For tips on how to work together, see "How to collaborate with CM counterparts," in this issue.) "The health care system has become so fragmented and so complicated, and people tend to work in a vacuum. The case manager should bring the whole team concept back," he suggests. "It’s not always possible for everybody to be physically together, but there should be a common link of communication."
Cesta’s case management department has forged a collaborative relationship with payer case managers who work on-site. (For details, see "On-site case manager creates win-win situation," in this issue.)
Wolfe calls for enhanced communication and suggests that all case managers articulate their set of care management goals for the patients. "It’s really the patient’s plan. You should show how the plan and case management work for that patient regardless of the setting," he says. "Everybody should know what the real goal is, whether the person is in the hospital, home care, or the ambulatory setting."
For example, home care case managers may be involved in only part of the plan. However, they should understand how they fit in, what is going to happen, and how the patient moves across the continuum, he adds.
If the patient is moving through the continuum, case managers should forward their care plan with the patient so the case manager in the new setting can continue working on the same plan, Wolfe says. "You wouldn’t think of discharging a patient to another provider without sending medical information along," he notes. "Why pass a patient to another case manager without sending a case management plan?"
Wolfe, a case manager in independent practice, has experience working with other case managers across the continuum of care. "The biggest challenge is getting people to share the information. It takes some time and effort to make sure the plan wends its way along, but it really gets down to basic communication," he says.