Let’s Get Together – Collaboration and Case Management
BY NANCY SKINNER, RN-BC, CCM, ACM
The very first case manager I ever met was a workers’ compensation case manager. As a young nurse practicing in a metropolitan hospital, I provided direct care to patients who experienced significant full-thickness burns. That was over 40 years and, yet, I continue to remember one patient who was injured in an industrial accident. Initially, his prognosis was poor with little expectation that he would survive.
As the interdisciplinary team cared for him over several months, we became familiar with his visitors, including his wife, a few co-workers and a nurse who represented his employer. Being a bit skeptical, we never fully understood the role of this “insurance” nurse. Hospital administration advised us to be cooperative but carefully “filter” any information shared with this “person,” who was described as a representative of the insurance company. One day while I was doing a comprehensive dressing change, the patient began to describe how this “insurance” nurse was a “blessing” to him and his wife. He described this nurse, or as he called her, “his case manager,” as a person who was helping him to someday return to work. He said, “She is already planning for the help I will need after I leave the hospital” and how she was beginning to put plans in place for him to ultimately return to work. He described her as the one person who saw beyond his current needs to identify the care he would require tomorrow to help him to once more have a productive and happy life.
This discussion prompted me to learn more about the role of the case manager. After the patient was discharged from both acute care and a comprehensive rehabilitation program, I learned this patient did ultimately return to work.
Even as I became a case manager myself and matured within the profession, I never forgot the professionalism displayed by that workers’ compensation case manager so many years before. She fully represented the intent of the Standards of Practice for Case Management long before the Case Management Society of America thought to develop them. She advanced the mission she described to me — a mission of promoting the efficient use of healthcare interventions and facilitating the injured employee’s return to work.
Fast forward 10 years: I was attending a large national case management conference, and I recognized the case manager who coordinated care for my patient so many years prior. While she did not remember me, she did remember the patient and the case management processes she employed to advocate for the patient. While she celebrated the outcome the patient achieved and her role in the patient’s ultimate return to work, she expressed frustration with a lack of collaboration between the healthcare professionals who performed a care coordination function and herself as a case manager who represented the payor, the employer and, most importantly, the patient. Although I imagined we had reached a state of cooperation and collaboration, she stated that the delivery of information regarding patient status, anticipated care needs, continuing care providers and expected course for additional interventions was fragmented and not provided in a timely manner. She also stated that a lack of effective and efficient communication negatively impacted her ability to facilitate patient access to necessary care and services.
Surprised by her comments, I looked to my own practice and considered the degree to which I partnered with other case management colleagues, only to realize I did not consistently collaborate or provide the necessary handover of information as patients moved outside the reach of my practice. While I endeavored to more fully interact with case management colleagues, efficient avenues for communication and collaboration with those colleagues became even more compromised by concerns regarding the protection of health information, a lack of interoperability of electronic health information systems and time restraints.
Now as a case management consultant and educator, I more fully realize the degree to which the profession of case management has become siloed. Case managers who represent a variety of unique practice settings may not consistently communicate and collaborate with each other. Additionally, the numbers of those varied case management practice settings are rapidly expanding as the efficacy of case management interventions is recognized by legislators, regulators, other healthcare professionals and, most importantly, by the patients and families we serve.
Patients may interact with more than one case manager as the patient moves through the healthcare continuum or as a patient seeks to manage a chronic disease state. One patient recently stated she had encountered six case managers as she received treatment for a significant injury related to a fall that caused pelvic and lower extremities fractures. She listed case managers who represented acute care, an inpatient rehabilitation facility, a home health agency, a community-based rehabilitation program, the primary care physician and the payer. She stated, “They didn’t talk to each other, and I became the one who shared information between them, and I didn’t think that was my job.”
There is a point to my rather lengthy story, and that point is the absolute necessity of bringing down the silos that inhibit greater collaboration among case management professionals. The Standards of Practice for Case Management, as presented by the Case Management Society of America, define case management as “a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote patient safety, quality of care, and cost-effective outcomes.” Those Standards also state that “the professional case manager serves as an important facilitator among the client, family or family caregivers, the interprofessional health care team, the payer and the community.”
If we are to collaborate, facilitate and advocate for our patients across and through each transition of patient care, we must bring down the silos that inhibit the timely, efficient and effective flow of information from one case manager to another.
During the comprehensive assessment process case managers perform, the information gained and shared with other case managers should not be limited to information mandated by regulatory or payer organizations or required by electronic systems. Each assessment should be expanded to include questions that represent the patient’s biophysiosocial status as well as current or previous interventions provided by a professional case manager.
My request, or “ask,” is for each case manager to consider the true value of collaboration and partnership with other case managers in order to advance the patient’s ability to achieve the individual goals that are significant to that patient. While some may believe this to be unrealistic based on the multiple responsibilities case managers accept, I encourage all case managers to consider developing strategies that promote effective collaboration between all case managers in order to advance timely and efficient handovers as the patient transitions through and across each transition of care.
Case managers understand that the value of our interventions has not yet been fully appreciated. Although our practice has evolved greatly from the initial efforts of the healthcare professionals who developed the fundamental components of our practice, case managers continue to journey toward the ultimate recognition of case management as a vital and essential element of healthcare delivery, not only in America but globally. It is said that any journey of a thousand miles begins with one step. As case managers, we have taken those first steps and have moved forward in that journey. One more step that case managers may wish to take is full identification of and collaboration with other case managers who coordinate care for our patients. In doing so, we advance not only our patients’ goals and healthcare experience, but also promote greater respect for the value each case manager brings to their patients, their employer and the community they serve.
And, as always, thank you for all you do advance the individual and global practice of case management.
Nancy Skinner, RN-BC, CCM, ACM, was CMSA President from 1998-1999 & 2012-2014.
Photo credit: ©iStock.com/fotostorm