Authors

  1. Harkey, Jane RN-BC, MSW, CCM

Article Content

It is a seemingly simple statement that can change everything: "I'm a case manager, and I'm here to help." For patients and their families or other support systems, this statement is often welcomed as an invitation to express what they want and need. Instead of being told what to do, as is too often the experience or perception in health care, people feel that they are in charge; they are the ones identifying their health goals and making decisions.

 

As a case manager with a background in both nursing and social work, I specialize in geriatric case management. Often, my initial contact is with an adult child who may be dealing with a parent who is resistant to change, including having a case manager. In these instances, the question "how can I help you?" asked of the parent and the adult child often opens the door to establishing the kind of rapport that helps people process and accept change.

 

Many times an adult son or daughter will call me aside with a warning: "Mom will probably try to throw you out of the house," or "You could have a tough time with Dad." When I meet resistance, I never take it personally-nor should any professional case manager. It's not about us. Patient-centered practice puts the individual at the center of the case management process. It's our job to facilitate conversations that ultimately educate and empower individuals in their decision making. For example, an elderly woman initially rejected the idea of having a home health aide, telling me: "I don't want a stranger in my house." In response, I encouraged her to think about it differently by asking, "If you had a home health aide here, how could that person help you?" This invitation to think about the possibilities and to make choices that would work for her changed the dynamic of the conversation. No longer did she feel that someone was going to show up in her house without her having a say.

 

Ensuring that the patient is empowered to make decisions is the heart of autonomy, one of the ethical principles of case management as defined by the Code of Professional Conduct for Case Managers, published by the Commission for Case Manager Certification (CCMC). Autonomy is a person's "right to self-determine a course of action..." in support of "independent decision making" (CCMC, 2015, p. 5). Professional case managers, and especially those who are board-certified, have an ethical obligation to deliver case management services in a way that encourages and supports autonomy. Potentially undermining the individual's sense of autonomy is loss, which is often experienced by older people, as well as by individuals with serious illnesses or severe injuries. Within the geriatric population, for example, people may be dealing with retirement and the loss of social interaction at work, the loss of a spouse and/or other people close to them, and/or the loss of independence (e.g., no longer being able to drive). By understanding that these are difficult adjustments, the case manager displays empathy and the ability to "meet people where they are."

 

As my CCMC colleagues and I wrote in the article "Meeting People 'Where They Are': Case Managers Empower and Motivate Clients to Pursue Their Health Goals," which appears in this issue, professional case managers take a patient-centered approach to address the individual's goals. This approach is crucial when trying to engage individuals who appear to be ambivalent or "stuck" in engrained health and/or lifestyle habits. As the article discusses, and as research by Judith Hibbard, PhD, demonstrates (Hibbard, 2016), these individuals are not unmotivated; rather, they are unable to move forward for a variety of reasons. Professional case managers can help patients become more engaged by tapping into their desires and goals.

 

Working with my clientele, I often uncover motivations related to family members-for example, the elderly person who wants to see a grandchild graduate from college or get married. By asking questions about what matters most to the individual-what is happening in his or her life and within his or her support system-these motivations can be unearthed. Tapping into deeper and often hidden motivations is crucial when a health goal requires change that is difficult; for example, quitting smoking or losing weight, especially if the person has struggled with previous attempts. Repeated past failures are demoralizing, to the point where it becomes increasingly difficult to make another attempt. But that's not to say these changes are impossible, as many of us have seen in our work with clients. Often, though, this involves small, incremental steps in the right direction. An example is a woman I worked with who, after more than 40 years of smoking, was able to reduce from a pack-and-a-half to five cigarettes a day. Parsing the process into smaller steps made her feel that the goal could be attained eventually. Every cigarette not smoked was a victory and encouraged her on the way to complete cessation.

 

Another example of motivating an individual in the midst of change is when people are newly diagnosed with diabetes and suddenly faced with needing to change/monitor their diets, test their blood every day, and give themselves insulin injections. For some people, these changes are upsetting to the point of being perceived as catastrophic. Or, the individual may not have a support system willing to facilitate the necessary health and lifestyle changes. Meeting people "where they are" can happen only when the case manager eliminates judgment and works to find solutions within the context of that person's life circumstances. In the case of a newly diagnosed diabetic, 1 day of training by a home health nurse may make all the difference in achieving a successful health outcome-and potentially avoiding costly emergency department treatment and hospitalization.

 

In order for patients to be engaged, they need to be empowered with information. When they understand the options, they can make informed decisions that are aligned with their goals-whatever they deem them to be. Consider the individual who was over the age of 90 years and diagnosed with cancer. After weighing all her options, the woman decided to refuse treatment and opted for palliative care. That was her decision, and given that she was mentally competent, she could make a decision that she felt was right for her particular phase of life.

 

Meeting people "where they are" is the start of a relationship between the case manager and the person, one that is built on trust and mutual respect. Often, it can begin with a simple statement that invites discussion about the person's wants, needs, and goals: "I'm a case manager, and I'm here to help."

 

References

 

Commission for Case Manager Certification. (1996, Revised 2015). Code of professional conduct for case managers. Retrieved from https://ccmcertification.org/sites/default/files/downloads/2015/0000.%20Code%20o[Context Link]

 

Hibbard J. (2016). Motivating the unmotivated client. Care Management, 22(3), 9-12. [Context Link]