In late 2019, the outbreak of a novel coronavirus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was confirmed in Wuhan, China. By the end of January 2020, nearly 8,000 cases of the coronavirus disease known as COVID-19 were reported worldwide, most of them in China, with a limited number of cases reported in 18 other countries (World Health Organization [WHO], 2020a). Contagion continued to spread globally, and on March 11, 2020, a pandemic was declared by WHO (2020b). As of this writing, in November 2020, global cases have grown to nearly 53 million, with global deaths of nearly 1.3 million reported (Johns Hopkins Coronavirus Resource Center, 2020).
The challenges surrounding COVID-19 have been profound. As Jean et al. (2020) summarized the first months of the global public health crisis:
We are facing a terrible virus with greater infectivity than the SARS-CoV pandemic of 2003. There is presently no vaccine or documented specific anti-SARS-CoV-2 drug regimen to treat critically ill patients. Most of the potential drugs for treatment of COVID-19 are being investigated for safety and efficacy against SARS-CoV-2. (p. 441)
Amid uncertainties such as how best to treat patients exhibiting a wide range of symptoms and severity of symptoms, professional case managers have emerged as key players in the frontline response to the pandemic in acute care, subacute care, home health, and other care settings. As Tahan (2020) observed, "Case management leaders and professionals are ... poised to play an essential role in supporting health care organizations, providers, and other agents in their responses to the COVID-19 crisis" (p. 249).
Professional case managers take an inherently individualized approach grounded in care coordination to provide the right care and treatment at the right time (Sminkey, 2016). The experiences of the authors of this article, all of whom are board-certified and either actively manage COVID-19 cases or direct the management of these cases, underscore the importance of the individualized care plan. Case managers are on the front lines of coordinating care for patients with COVID-19 who exhibit varying degrees of symptoms and whose symptoms can vary day to day, amid great uncertainty and unknowns about the pathogen. In addition, and as addressed in this article, individualized care plans address COVID-19 risk prevention for severely ill and injured individuals who may, because of their health status, spend months in acute care and/or subacute care settings.
In providing care coordination and other case management services to individuals (known as "clients" or, in some care settings, as "patients"), professional case managers are guided by values such as advocacy, ensuring access to the right care and treatment at the right time; autonomy, respecting the right to self-determination; and justice, promoting fairness and equity in access to resources and treatment (Commission for Case Manager Certification [CCMC], 2015). The value of justice also addresses the sobering reality that, as the Centers for Disease Control and Prevention ([CDC], 2020c) stated: "Long-standing systemic health and social inequities have put many people from racial and ethnic minority groups at increased risk of getting sick and dying from COVID-19" (p. 1). Case managers, particularly those who are board-certified, have an ethical obligation to ensure to the best of their ability that care resources are available to all individuals receiving case management services. Such equity also helps support the Triple Aim of improving individual experiences of care, achieving better health of individuals and populations, and reducing per capita costs of health care (Berwick et al., 2008). The Triple Aim forms a foundation for ethical and professional standards in case management.
It should be noted that ongoing research and data about effectiveness of treatments, therapies, and vaccines will form an evolving body of knowledge and best practices for treating and preventing COVID-19. That voluminous research is beyond the scope of this article, which focuses primarily on the case management response in the field. Although some of the information presented here includes anecdotal evidence, it is based on actual interventions by experienced, professional case managers working on interdisciplinary teams to manage COVID-19 cases. Moreover, the case management examples and interventions discussed are all corroborated by current research and the latest information available as of this writing.
Case Management for Patients With COVID-19
On March 19, 2020, 8 days after officially declaring COVID-19 a pandemic (WHO, 2020b), WHO issued interim guidance, titled, "Operational Considerations for Case Management of COVID-19 in Health Facility and Community." The guidance, WHO (2020c) explained, "is meant to guide the care of COVID-19 patients as the response capacity of health systems is challenged; to ensure that COVID-19 patients can access life-saving treatment, without compromising public health objectives and safety of health workers" (p. 1). Case management has been a critical intervention in COVID-19 response and treatment, particularly in serious symptomatic cases. Individualized care plans provide access to the right care and treatment at the right time to address both the consequences of the disease and patient comorbidities.
The Case Management Society of America ([CMSA], 2017) defines 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. (p. 1)
Similarly, CCMC (2015), in its Code of Professional Conduct for Case Managers ("Code"), defines case management as:
A professional and collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual's health needs. It uses communication and available resources to promote health, quality, and cost-effective outcomes in support of the "Triple Aim," of improving the experience of care, improving the health of populations, and reducing per capita costs of health care. (p. 3)
As key members of interdisciplinary teams, professional case managers have been directly involved in addressing the challenges of COVID-19 by devising care plans for individuals, helping keep health care workers safe, and assisting with contagion prevention within facilities and the community.
As advocates, professional case managers acknowledge that their first duty is to their patients (clients) and their families/support systems, by coordinating care that is safe, timely, effective, efficient, and equitable (Case Management Body of Knowledge [CMBOK], 2012-2020). Taking an individualized approach is foundational to advocacy. For example, when managing myocardial infarctions (or "heart attacks"), case managers know that recovery can differ from patient to patient based on health status, the presence of comorbidities, and other circumstances. With COVID-19, the same person-centered approach applies, particularly because patient trajectories can be complicated and unpredictable. As research has shown, COVID-19 exhibits a great deal of unpredictability: who it strikes and how severely each person is impacted. The CDC, in reporting findings from a study of patients with COVID-19 from China (>44,000 people), stated that 81% exhibited mild to moderate symptoms (up to mild pneumonia). Another 14% of patients showed severe symptoms, such as dyspnea (labored breathing) and hypoxia (lack of oxygen in the body), and more than 50% exhibited lung involvement on imaging. The remaining 5% of patients had critical symptoms, including respiratory failure, shock, or multiorgan system dysfunction (CDC, 2020b).
The CDC further advised that individuals face increased risk of experiencing severe illness from COVID-19 due to the presence of certain underlying medical conditions, including cancer, chronic kidney disease, chronic obstructive pulmonary disease, immunocompromised state (such as from solid organ transplant), obesity, coronary artery disease and other serious heart conditions, sickle cell disease, and Type 2 diabetes (CDC, 2020d). Furthermore, Liu et al. (2020) observed that patients with COVID-19 who had preexisting cardiovascular disease, hypertension, and related conditions often experienced worse outcomes than others with COVID-19. In addition, patients with COVID-19 may experience cardiac injury due to the impact of the coronavirus on the body. Furthermore, there is evidence that people who have moderate to severe asthma and who contract the coronavirus may be at a higher risk of experiencing asthma attacks, pneumonia, and acute respiratory disease (CDC, 2020e). As these findings indicate, the challenge in managing more serious and severe COVID-19 cases is not only in treating symptoms caused by the coronavirus infection but also in managing underlying, preexisting conditions, as well as complications from the viral infection, including the negative impact on major organs.
Given the unknowns and unpredictability of the disease, and a rapidly evolving pandemic, the initial major challenge for frontline case managers was ensuring procedures were put in place for managing a range of patients: those who were symptomatic but able to self-isolate and care for themselves at home; those who had serious symptoms and needed to be hospitalized; and those who were asymptomatic and needed to be educated about the importance of self-isolating. Across the care spectrum, individualized responses to the clinical and psychosocial needs of patients with COVID-19 in acute care, subacute care, home health, and other outpatient settings have been guided by the well-established case management process of screening, assessing, planning, implementing, following up, transitioning, and evaluating. During the planning phase, care goals are established and actions (both treatments and services) are determined for meeting the individual's needs (CMBOK, 2012-2020). Although always important, planning becomes even more urgent and challenging when managing COVID-19 cases, as well as to reduce risk of exposure for individuals currently in the health system (see Box 1).
BOX 1
Addressing Variability of Symptoms
Professional case managers on the front lines of the COVID-19 response have learned much about the disease in their interactions with patients and clinicians and as members of interdisciplinary teams. This is consistent with the fact that case managers typically learn much about the practice on the job (Tahan et al., 2020). From the earliest days of the pandemic, it became evident that COVID-19 cases varied greatly, in terms of how the disease presented in patients, the severity of patients' symptoms, and even with fluctuations in symptoms from day to day. For example, a case manager checked in with an individual who had tested positive for COVID-19 but who was able to self-isolate at home. "I have no symptoms today," the person said. "But yesterday, I would have told you that I may need to go to the hospital because I couldn't catch my breath."
Another observation from case managers was the exacerbation of mental health issues and disorders due to COVID-19. As one of the article authors who works in a Level 1 trauma unit in California observed, many of the people who sought treatment of COVID-19 symptoms such as difficulty breathing were also in mental health crisis, experiencing stress and anxiety, as well as heightened worries about loss of income because of the illness, providing for their families, and protecting others from contagion. This also became evident among patients who were recovering at home. Many had new or recurrent depression and anxiety symptoms related to fears for their health and/or fear of losing financial resources. Research corroborates this observation. Colizzi et al. (2020) found evidence of heightened concerns about the psychological impact of COVID-19 among the general population, and in particular among people suffering from preexisting mental health conditions and/or psychiatric disorders. To address such patient needs, case managers reported the benefit of involving a behavioral health therapist in patient communication, specifically to listen to what the individual was reporting from a psychosocial perspective.
Some mental health symptoms experienced by patients with COVID-19 who were hospitalized or who sought care in the emergency department can be treated in the acute care setting, such as with medications. However, longer term resources for managing mental health may be challenging because in-person resources such as support groups, group therapy, and one-on-one psychotherapy have not been widely available during the pandemic. Telephonic and online consultations (e.g., "telepsychiatry") have been used to some success among patients with access to the technology and who were comfortable using it (Kasckow et al., 2014). However, telepsychiatry may not be suitable for all patients. An obvious drawback is the lack of access to technology (e.g., internet and a computer or other device), but there are other considerations. For example, some schizophrenia symptoms, including visual and/or auditory hallucinations, may make it difficult for some patients to interact with a therapist or psychiatrist via a computer screen or smartphone. This example underscores the importance of an interdisciplinary team approach to ensure that the specific needs of individual patients are understood in order to provide the most effective care and treatment protocols.
Coordinating care for patients with COVID-19 also requires knowledge of social determinants of health that impact the treatment of symptoms and prevention of further contagion within their community. For example, research indicates that homeless people who have COVID-19 are potentially two to four times more likely to require critical care and two to three times more likely to die compared with the general population (Culhane et al., 2020). Responding to these needs often requires a community-based effort, coordinated at the local and state levels. For example, in California, Project Roomkey has used Federal Emergency Management Agency funding to provide more than 15,000 hotel rooms to help homeless people awaiting COVID-19 test results or who have COVID-19 but do not require hospitalization (including those who are asymptomatic) to help them self-isolate safely and with support (California Health Care Foundation, 2020). Another example is Kaiser Permanente, which provided $1 million to increase capacity for preventing and treating COVID-19 disease within the nation's homeless population in collaboration with the National Health Care for the Homeless Council (Kaiser Permanente, 2020). Such solutions emphasize the importance of flexibility and collaboration on the part of interdisciplinary teams working with community and state agencies to find solutions for individual patients and to help manage population health (see Box 2).
BOX 2
In-Person Supervision for a COVID-19 Patient With Dementia
Another lesson learned on the job by case managers was the importance of addressing both the physical and mental health needs of individuals with COVID-19. An example was case management provided to an elderly man who lived alone in senior citizens housing and who tested positive for COVID-19. He exhibited mild symptoms that did not require hospitalization. However, he was also in the early stages of dementia, which impaired his ability to understand his restrictions, especially self-isolation for 14 days. A case manager worked with his insurance company to pay for home visits and phone calls from nurse practitioners to monitor the man's symptoms, gather information to be communicated with the primary care provider, and reinforce the need to quarantine.
Protecting Severely Ill/Injured Individuals From COVID-19 Contagion
A person-centered approach to case management takes on another dimension when managing cases involving severely ill and injured individuals. Individuals who have suffered spinal cord injuries, traumatic brain injuries, severe burns, and other catastrophic injuries can spend extended periods of time in acute care and subacute settings as they receive treatment and rehabilitation. Typically, field case managers act as the "eyes and ears" who observe and assess the needs of severely and catastrophically ill and injured individuals as care is provided along the continuum (Baker, 2020). COVID-19, however, has changed how field case management is being carried out in two significant ways. First, in addition to ensuring these individuals receive the care and treatment they require, field case managers must manage the risk of exposure to COVID-19 while these individuals are in health care facilities. The CDC has provided guidelines for health care facilities to guide care provision in the emergency department, in-patient, intensive care, urgent care, outpatient, and home-based care settings, while minimizing risk of exposure to patients and health care personnel (CDC, 2020a). Second, field case managers must now manage catastrophic cases and observe recovery telephonically. Although telephonic and virtual case management, as is discussed, is being practiced more frequently across the health and human services spectrum, in managing catastrophic cases, it has presented a new level of challenges: for example, how best to transition care for a severely injured person from one facility to the next while mitigating COVID-19 contagion risk and ensuring that psychological support needs are met during times when isolation and decreased person-to-person contact are mandated.
One of the authors of this article who directs catastrophic case management among a team of professional case managers described reengineering processes when on-site case management was no longer possible. Meetings with patients and care providers were moved to virtual platforms, although some physician practices and facilities were slower to adopt telehealth than others.
Although technology has allowed for frequent virtual communication to continue, there remains the challenge of differing levels of care provision in different geographic areas or even between individual health care providers; for example, some allow in-person care to continue and others not. The challenge of ensuring well-rounded care provision to patients and to serve as the "connector" between patients and care providers has increased manifold. Yet, the priority remains to efficiently navigate the care configurations of each individual provider and region (see Box 3).
BOX 3
Field Case Management in the Time of COVID-19
The experience of field case managers who handle catastrophic cases shows the importance of being flexible and adaptable amid changing conditions. Typically, field case managers act as the "connectors" between care providers/facilities and patients and their families/support systems. During COVID-19, these case managers have had to adjust to new ways to coordinate with the care team within the care settings where their patients are being treated. This includes using smartphone apps and teleconference software. In addition, connecting with patients and observing their recovery are accomplished via technology. In some instances, this involved providing small tablets or smartphones to enable patients to have virtual contact with the case manager, their physicians, and other providers.
Catastrophic case management in the time of COVID-19 also must respond to the needs of homebound patients who cannot isolate by themselves, while reducing the risk of contagion for both the individuals and the health care workers attending to them at home. For example, ensuring proper personal protection equipment supplies and usage allows home health care workers to provide services to patients with severe injuries who need assistance with daily activities. As this discussion shows, addressing the needs of patients and health care workers (as well as family members acting as caregivers) has added another layer of complexity while advocating for individuals and their support systems/families.
Supporting Patients With COVID-19 Using Telephonic Case Management
As the example of managing catastrophic cases shows, case managers in many care settings have shifted increasingly to telephonic case management and other telehealth tools. As Tahan (2020) states:
In this current COVID-19 crisis, it is necessary for case managers to expand the use of telehealth as a tool to provide timely care to patients and their support systems whether they are at home, in an acute care setting/hospital, or at another setting across the continuum of care. This approach has quickly become a common and important method in caring for patients while preventing further exposure to COVID-19. (pp. 251-252)
An example is Kaiser Permanente Washington, where one of the authors of this article is a case management clinical practice specialist. The first confirmed case of COVID-19 in the United States was in Washington State: a 35-year-old man treated in an urgent care clinic (Holshue et al., 2020). As cases in Washington State increased, Kaiser Permanente Washington, which is a health plan and health provider, quickly increased access to care through telehealth to ensure that patients were able to receive timely care while reducing the risk of contagion for themselves and the community during a state-imposed stay-at-home order.
At the same time, Kaiser Permanente Washington's Care Management utilized teams of case managers to reach out to patients who had tested positive for COVID-19 to provide assessment, symptom management, and guidance on how to obtain care or, when more appropriate, how to self-isolate and recover at home. To handle the surge in the number of COVID-19 cases, these telephonic teams included case managers and other health care professionals, with additional help from nurses from ambulatory units that had stopped performing elective surgeries. Patients stayed on the Care Management registry and received outreach on an ongoing basis until their symptoms resolved.
Frequently, outreach has gone beyond clinical needs to providing human contact with those in quarantine. During such contact, case managers often display compassion and a willingness to listen, particularly to those who experience the emotional impact of the effects of the disease on their own health and on their loved ones. For example, a case manager related the story of a man who told her, "I tested positive and had no symptoms. But my wife just passed away in the hospital from COVID-19. How can that be?" Such telephonic interactions with patients serve as a reminder of the importance of displaying empathy whenever case managers engage with individuals and their support systems. During in-person interactions, empathy is conveyed both verbally and nonverbally, including with gestures and facial expressions. Telephonic and digital connections rely largely on tone of voice and word choice to show empathy. As Mann (2020) states, "Case managers must demonstrate that they know where the client is coming from, what challenges or obstacles they face, and what support and resources they need. The differentiator is empathy, whether communication occurs in person, telephonically, or digitally" (p. 299). Although empathy should always be conveyed, COVID-19 makes this emotional connection even more important when communicating with those who may be dealing with worsening symptoms during isolation at home or in the hospital without visitors, as well as families/support systems who are unable to be with dying loved ones (see Box 4).
BOX 4
A Human Connection
Case managers on the front line also described the importance of empathy in their communication with patients and their families/support systems. Specifically, as case managers engaged in outreach to patients during COVID-19 have related, the experience is a reminder of the importance of human connection. One case manager shared that "the most important thing to do is pause to listen to the patient. We need to show them, 'I hear you, I am here for you, and I am with you.' That reminds us of why we became case managers in the first place."
Self-Care and the "Fourth Aim" in the Time of COVID-19
Although this discussion focuses primarily on the case management response to COVID-19 in the field, it would not be complete without also acknowledging the importance of self-care among case managers and other clinicians and caregivers. As discussed, the Triple Aim guides the provision of care and treatment of individuals receiving case management services. The Quadruple Aim adds another component: improving the work life of clinicians and caregivers to prevent burnout that can lower patient satisfaction and reduce health outcomes (Bodenheimer & Sinsky, 2014). During COVID-19, physical, mental, and emotional exhaustion, stress, and burnout experienced by doctors, nurses, and other clinicians create greater urgency for understanding the fourth element of the Quadruple Aim (Hu et al., 2020; Matsuo et al., 2020). The inability to spend leisure time with family, friends, and colleagues due to social distancing compounds the problem.
Although a comprehensive discussion of the Fourth Aim in the time of COVID-19 is beyond the scope of this article, it is crucial to acknowledge the importance of self-care, rest, and talking to others to prevent burnout. In addition, conference calls and team meetings held virtually allow not only sharing of best practices and patient management procedures but also opportunities for people to reconnect with their community of colleagues. Case managers feel the effects of the pandemic not only professionally but also personally in the impact on their own families and loved ones. They show empathy to colleagues who have known someone who has been sick or passed away from COVID and/or who are experiencing other stresses and concerns, such as homeschooling children and caring for aging parents. The Quadruple Aim makes it imperative to pause, reflect, and refresh. Individual case managers have shared how they experience moments of self-care through activities such as riding a bicycle, taking walks, and being in nature. In addition, self-reflection and mindfulness have helped case managers feel, as has often been expressed during the pandemic, that "we're all in this together."
Conclusion
The lessons learned from COVID-19 continue to emerge and, no doubt, will for years to come. Among the important takeaways thus far is the vital role of professional case managers who can take the lead when dealing with the unknown and uncertainty to provide for individualized care for patients. By relying on their knowledge and skills, with guidance from the ethical and professional principles contained in the Code, professional case managers across the care continuum will continue to be the go-to resources to help coordinate care in the frontline response to COVID-19.
References