Guest Column

Don't neglect contributing factors in assessment

CMs should consider 'whole patient'

By Jolynne "Jo" Carter, BSN, RN, CCM
Paula Gelber Dromi, PhD, LCSW
Commissioners, Commission for
Case Manager Certification

Millions of Americans live with chronic conditions: diabetes, hypertension, arthritis, pain, and myriad other illnesses and injuries. When chronic conditions worsen or unrelated acute episodes occur, hospitalization may become necessary.

For individuals who have chronic conditions — including older adults who may have several health issues and who may have been prescribed numerous medications — concerns go beyond the immediate clinical needs. Hospital case managers, therefore, must devise a care plan that addresses not only the acute-care episode, but also considers the chronic conditions and other contributing health factors.

The challenge for hospital case managers is that when a patient is hospitalized, most of the attention is on the acute episode, especially given insurers' allowance for the number of days for treatment and hospitalization. Targeting only the acute problem through clinical treatment and intervention, however, may de-emphasize chronic conditions and other contributing health factors so that important connections are not made.

Consider a person who is a quadriplegic after suffering a spinal cord injury 20 years ago, who has been hospitalized for his first skin breakdown. Because this condition is potentially very serious, treatment focuses on preventing infection and promoting healing. The case manager who looks at the patient holistically, however, considers other factors; for example, when was the wheelchair cushion last replaced and has the patient changed his mattress recently? Psychosocial considerations are also important: Did he change his caregiver or experience a loss of relationship recently?

Another contributing factor that must be taken into account is a change in personal circumstances, particularly for those coping with chronic conditions such as pain. The death of a spouse may affect a person's ability to take care of one's self, keep track of medications, and/or prepare meals. The death of a loved one or a pet may trigger depressive grief, which further compounds the person's ability and even desire to care for themselves.

Case managers must consider all these factors as part of patient assessment and in the development of a care plan, particularly if the individual is elderly and has limited or no family or other support systems in his/her community.

Among chronic conditions, one of the most common is pain. There are many potential root causes, including musculoskeletal injury, nerve root compression, arthritis, complex regional pain syndrome, fibromyalgia, cancer, gastroesophageal reflux disease, or peripheral neuropathy.

When pain has been present for six months or longer, quality of life deteriorates. Pain that is often in the background when patients have multiple conditions becomes a chronic condition in and of itself. As chronic pain intensifies, it becomes the focus of the patient's inability to cope. Disruption of sleep caused by the pain can compound the situation and lead patients to seek out a variety of physicians who could prescribe changes in treatment and/or more or different medications. In addition to prescribed medications, patients may try to self-medicate with other drugs or alcohol.

If the patient becomes hospitalized for pain that has become unmanageable, the intersection of an acute-care setting and insurance company requirements may necessitate a clinical response, including surgery. Post-surgery, the patient may be prescribed narcotic drugs, raising the potential for addiction, which triggers yet another cycle of intervention.

Conversely, elderly patients may be living with unacceptable levels of pain. According to a recent report, at least 80% of older Americans are living with at least one chronic condition and 50% have at least two.1 As older adults experience acute and chronic pain, however, their reaction may be more stoic, largely because they believe the discomfort they experience is simply a part of aging, and there is nothing they can do about it. However, there is a correlation between pain and progressive symptomology. As health declines and sleep is disrupted, there is often an increase in depression, loss of interest in activities, and self-isolation, which further compounds individuals' ability to cope and care for themselves. Case managers should be on the lookout for the impact of chronic pain on the overall plan of care.

When patients have one or more chronic conditions, case managers must address not only the clinical and pharmacological aspects of a case, but also the patient's psychosocial and spiritual needs. A comprehensive assessment is even more important when dealing with chronic health conditions and pain.

Addressing psychosocial issues

Dealing with psychosocial and spiritual issues, the hospital case manager may reach out to other members of the treatment team, such as social workers who have expertise assessing behavioral health, including the person's mental state, and who can address the individual's family and social support. Case managers often have experience reaching out to community resources, from volunteers who will provide transportation to medical appointments to groups that will deliver meals.

After an acute care treatment episode, patients are often discharged to the home environment with many ongoing medical and therapeutic needs. For many patients, including the elderly who may live alone or with an aged spouse, a key resource is home health care. Home health care provides continuity of treatment from the acute care setting into the home environment. When a patient is considered higher risk for hospital readmission or has difficulty providing self-care, home health care is an effective way to ensure a safe and successful transition from the hospital to the home setting.

In order for the home health care provider to deliver the right care and services to the patient post-discharge, there must be clear communication from one treatment setting to the next. The hospital case manager, the case manager at the insurance company, the treating physicians, and the home health care providers must have access to the same information, including details about the acute episode, the presence of chronic conditions, and a list of prescribed medications and other supplements or nonprescription medicines that the individual takes.

For many people, managing chronic conditions is a way of life. Through comprehensive, effective case management, these individuals can improve their health — both physical and mental — remain safely in their communities, and enjoy a higher quality of life.

(Editor's note: Jolynne "Jo" Carter, BSN, RN, CCM, is a commissioner with the CCMC. She also is director, network services at Paradigm Management Services LLC, accountable for the day-to-day management of Paradigm's national network of nurse case managers, which includes about 130 registered nurses across the United States. Paula Gelber Dromi, PhD, LCSW, is a therapist, consultant, and educator, with a specialty in geriatric case management, and is also a commissioner with the CCMC.)


  1. Centers for Disease Control and Prevention and The Merck Co. Foundation. The State of Aging and Health in America 2007. Whitehouse Station, NJ: The Merck Company Foundation.