Patient-Centered Plans and Authentic Case Management
BY MARY MCLAUGHLIN-DAVIS, DNP, ACNS-BC, NEA-BC, CCM
Recently, I sat with a fifty-eight-year-old stroke patient at a skilled nursing facility (SNF). The patient had a history of alcohol abuse and smoked a pack of cigarettes a day. He had a wife, five sons and a granddaughter. The patient had significant deficits from the stroke, and the potential for his returning home was poor. Based on the patient’s medical picture, it appeared it would be relatively easy to write a care plan and create the goals to match the plan. When I asked the patient what he would like to accomplish, he replied, “Rest. I’m so tired, and I want to see my son and my granddaughter.”
There are frequent references to “patient-centric care plans” in health policy, health care standards and case manager literature. Case managers promote patient- or client-centered plans as a necessary component for authentic case management practice (CMSA 2016).
The challenge for case managers is to step back and allow the patient and his designated caregiver to create their own care plan and define their subsequent goals. This may require a change in paradigm for the case manager who previously directed care and set the goals for the patient care plan. At the heart of a patient-centric plan is the relationship between the case manager and the patient. The case manager learns the patient’s priorities, and the patient learns to trust the case manager. The mutual respect within the relationship allows the patient to design a personal plan of care and to set goals for the plan. The patient’s plan and goals may not be directly related to curing disease or health promotion, but the astute case manager will align the patient’s goals with health-related goals.
Our SNF patient was reclusive, and until his stroke spent all of his time at home with his wife, with periodic visits from his son’s family. The familiar routine was abruptly disrupted, causing confusion and sadness for the patient. We confirmed with him that his therapy regime was exhausting and that he was homesick. With the patient and his wife, we developed a short-term plan for rest periods between his scheduled therapies. We also created a large schedule for the bulletin board with the dates the family would visit. The long-term plan was continued therapy for function and strengthening, with scheduled rest periods. The patient maintained his calendar for family visits and explored with his family the possibility of returning home with skilled and community support, as well as his commitment to maintain abstinence from tobacco and alcohol.
The patient-centric plan requires a relationship between the patient, the case manager and the interdisciplinary team. The case manager is the patient advocate, and it is incumbent on her to listen to the patient and connect his plan and goals to plans that lead to the personalized goals of improved health. ■
CMSA, (2016). Standards of practice for case management, revised 2016. Case Management Society of America.
Mary McLaughlin-Davis, DNP, ACNS-BC, NEA-BC, CCM
President, CMSA 2016-2018
Dr. McLaughlin-Davis is the president of CMSA. She has been a certified case manager since 1993; she is a clinical nurse specialist for adult health and the senior director for care management for Cleveland Clinic, Avon Hospital.
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