Case Management at the Helm of Diverse America
BY JOSE ALEJANDRO, PhD, RN-BC, MBA, CCM, ACM, FACHE, FAAN
Martin Luther King, Jr. was quoted in 1964 as saying, “Of all the forms of inequality, injustice in health is the most shocking and the most inhuman.” Over fifty years later, our society continues to struggle with creating a healthcare system that has the ability to meet the cultural needs of the diverse people we serve. As case managers, we are very familiar with how social determinants impact care delivery and wellness overall. As leaders, how can we make a difference in our global community?
Leading in an environment of continuous change is daunting and exhausting. Over the continuum of care, the needs of the stakeholders we serve are constantly evolving. A successful organization has a culture that engages stakeholders, teams and our partners in embracing the organization’s mission and vision. As leaders, we need to apply key learnings about how we can strengthen a culture of learning within our organization. We need to consider the question, “How can we use a systems approach to reduce gaps and fragmentation of care within an ever-diversifying community?”
Melting Pot Becomes Larger
The non-Hispanic white population in the United States is projected to peak at 199.6 million in 2024, with a decline of approximately 20.6 million by 2060. Hispanics will see a significant boom in growth from 53.3 million in 2012 to 128 million in 2060. Hispanics will grow from one in six to one in three by 2060. The black or African-American population will see a slight growth from 41.2 million to 61.8 million in the same period. Asians will see a doubling growth during the same period of time, from 15.9 million to 34.4 million. The significance of this trend is that the younger generations are predominately minorities. In 2060, non-Hispanic whites will account for 43 percent; Hispanics 31 percent; blacks 15 percent; Asians 8.2 percent and other 2.8 percent. Two or more races will account for 6.4 percent of total population (United States Census Bureau, 2012).
Diversity within healthcare disciplines, such as case management, are not representative of current population trends. Registered nurse demographics include white 75.4 percent, black or African-American 9.9 percent, Hispanic 4.8 percent, Asian 3.6 percent and others 6.3 percent (Minority Nurse, 2015). Social worker demographics include white 87 percent, black or African-American five percent, Hispanic two percent, Asian two percent and others four percent (National Association of Social Workers, 2003). As leaders, how can we develop educational and career pathways that support the development of a more diverse workforce?
Three important factors that will continue to impact case management practice include: managed care expansion, a growing elder population, and increasing numbers of chronically complex individuals who are maintaining an improved quality of life as more innovative treatments and drugs are developed (Commission for Case Manager Certification, 2017). These factors are further compounded by the lack of resources, limited mental health services throughout the country and our changing demographics.
Our definition of “managed care” is transforming. As case managers, we are faced with a dichotomy — managing care of the individual and managing care of expanding groups of people across the continuum of care. Payment mechanisms continue to become more complex and chaotic. In order to reduce care transition disruptions, we need to become more familiar with how our continuum of care partners are paid for the care that they provide and the respective requirements and scrutiny of oversight agencies.
As the size of our elder population increases, we quickly have become aware of the importance of strengthening our relationships across the continuum of care. It is imperative that we consider how to effectively network with our peers and understand the diverse perspectives and needs of our partners. How can our professional association bridge the generations? How can we demonstrate the value-add of the case management professional?
Our global community continues to develop innovative ways of providing more complex and life-sustaining care. At the same time, we are faced with balancing the unique needs of the diverse individuals we serve. Many times, case managers are put into the untenable position of mediating between the individual and the payer. Our ability to critically think as reflective and objective professionals is challenged on a daily basis.
And finally, how do we advocate for our most vulnerable populations? We are all aware of our limited mental health and community support services. Our diversity creates pockets of haves and have nots, yet the healthcare community’s expectations of adherence to care plans does not differ between populations. How can we engage our stakeholders in collaborative relationships that build on our strengths?
What Does This Mean for Case Managers?
Case managers, in all settings, continue to be the leaders in care coordination, transitions of care, individual advocacy and promotion of patient reintegration into the community. Social workers and registered nurses continue to make up the bulk of the case management field. We must persist in working with other healthcare professionals to promote a transdisciplinary approach to improve individual outcomes and individual satisfaction while addressing cultural differences.
Case management models will need to evolve to address identified challenges. For example, social work models will need to transition from administrative to be more clinically based to address the advanced psychosocial needs within the acute care setting. This includes addressing the behavioral healthcare needs on a concurrent basis, instead of delaying until post-discharge. As we know, discharge planning is initiated at the time of admission. What we often forget is that discharge planning is recurrent and is a function of all healthcare disciplines. Failing to address the behavioral health components of a patient’s wellness fails to set that individual up for success.
We need to prepare our future leaders for continuous change. In the ideal learning culture, the foundational courses of all healthcare disciplines need to embed topics that address systems thinking and reflective practice that includes approaches to becoming culturally sensitive. Understanding our own mental models will allow us to become more prepared to address cultural differences throughout the healthcare continuum. As healthcare professionals, we cannot be expected to know every nuance of a particular population, but we must have the tools to understand what questions need to be asked and what approaches need to be utilized. Case management models must promote how to address cultural differences and how to access community resources to improve coordination of care, transitions of care and community reintegration. Oftentimes, healthcare providers will label individuals as non-compliant, but we must really ask ourselves, did we give the individual all the tools necessary to be successful? A more appropriate question is whether or not the individual is adherent to the proposed treatment or case management plan. We must be able to communicate effectively and at a level (and language) that is understandable.
Advocacy & Engagement
Case management advances clinical practice throughout the healthcare continuum regardless of practice setting. As professionals, we must include advocacy as part of the individual’s personalized care plan. Oftentimes, we mistake tasks as core functions of case management practice. We need to fully invest in individual advocacy, coordination of care, and advanced psychosocial interventions that will incorporate cultural beliefs. When we consider the needs of the individual, we build trust with that individual, his or her support network and the community. Building trust is essential for open dialogue to occur, which leads to the delivery of cultural sensitive care.
Case management professionals will need to seek partnerships that can assist us in addressing cultural differences as a core function of individual advocacy. These groups include the National Association of Hispanic Nurses, the National Black Nurses Association, National Association of Black Social Workers, Asian American Pacific Islander Nurses Association, National Hispanic Medical Association, and others. Oftentimes, these groups have developed strategies and toolkits on how to build trust within these communities, which can improve healthcare disparities and access to care at the right time. At the local level, organizational chapters can provide subject matter experts to assist in addressing how to work within these communities to improve health outcomes and adherence to care.
Engagement is about much more than just a satisfaction score. As case management professionals, think about the opportunity that you have in building relationships that assist others in recognizing similarities and differences. Building a healthcare environment that is responsive to individual needs is much more powerful than supporting a reactive case management approach. From a systems thinking perspective, how can we reduce rework? How can we incorporate the perspective of others in today’s care delivery models?
The ideal learning culture engages, empowers and expects stakeholders to challenge the status quo. Ideal learning cultures help individuals discover their passion. As a leader, we need to recognize that challenges, and even failures, are a part of learning and building resilience. As we move forward, let’s take on the challenge of becoming more thoughtful and resilient case management professionals. As the United States continues to become a larger melting pot, case management professionals must meet the challenges within care delivery which addresses cultural differences faced throughout the healthcare continuum. Case managers must embrace the significant role of advocating and engaging individuals to ensure improved patient outcomes, care transitions, and coordination of care.
Commission for Case Manager Certification. (2017). Case management facts. Retrieved on January 13, 2017 from https://ccmcertification.org/about-us/about-case-management/case-management-facts.
Minority Nurse. (2015). Nursing statistics. Retrieved on January 19, 2017 from http://minoritynurse.com/nursing-statistics/.
National Association of Social Workers. (2003). Practice research network: Demographics. Retrieved on March 26, 2017 from https://www.socialworkers.org/naswprn/surveyTwo/Datagram2.pdf.
United States Census Bureau. (2012). U.S. census bureau projects show a slower growing, older, more diverse nation a half century from now. Retrieved on March 15, 2017 from https://www.census.gov/newsroom/releases/archives/population/cb12-243.html.
Jose Alejandro, PhD, RN-BC, MBA, CCM, ACM, FACHE, FAAN, is the Director of Case Management at Tampa General Hospital, a 1,011-bed Magnet designated Trauma and Burn Center. Dr. Alejandro is the CMSA President-Elect as of June 2017 and was the 15th President (2012-2014) of the National Association of Hispanic Nurses.