1. Zydowicz, Dorothy J. BSN, RN, CCM, CDMS

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As a trainer, my task was to teach a group of nurses from a clinical setting what it means to be a case manager facilitate their successful transition into a case management role. During the class, I discussed the critical skill of multitasking, referring to it as "juggling" all the aspects of a claim. I described the complexity of case management as essentially keeping a variety of "balls" in the air at once: clinical and behavioral health components; psychosocial issues; multiple care providers including physicians, therapists, and social workers; potential barriers to communication and understanding; language or cultural differences and educational or developmental differences; other players from insurers to employers; and a host of other potential concerns from the safety of the home environment to the need for transportation.


That is not all, I explained, continuing with the visual analogy. With so many balls in the air at once, the skilled case manager needs to know which ones are made of rubber and which ones are made of glass. The rubber balls are those issues that lack criticality and will "bounce back" into one's focus again if not addressed immediately. Balls made of glass represent issues that carry time-sensitive criticality; if not addressed appropriately, the case manager's opportunity to make an impact will "shatter" and be lost forever. Knowing what is critical and when to focus one's attention on it is at the heart of case management best practices.


Now, I told the nurses, add to that the dynamic of delivering case management services telephonically. The individual for whom the case manager is advocating is probably someone he or she will never see. To the client (meaning the person receiving services), the case manager is nothing but a voice on the phone. This brings with it the added challenge of how to establish rapport and trust with the individual.


Telephonic case managers frequently face the added obstacle of perception in establishing rapport with the clients for whom they are advocating. Clients may have the initial impression that the case managers are working on behalf of the insurance companies or employers, instead of advocating for them. The client's perception may be that the reason a telephonic case manager has been assigned to them is to say "no" to care, treatment options, or other services.


Therefore, trust and rapport with the client need to be built through clear communication from the very first call. This includes disclosure of the case manager's roles and responsibilities, accountability to the client and to other involved parties, and commitment to the ethics and professional standards that govern the practice. Telephonic case managers need to convey the message that "I'm here for you; I advocate for you." First and always, the case manager must actually believe it!! One cannot possibly "fake" that conviction; it must be genuine as our ethical standards require.


Telephonic case managers work in a variety of settings, such as workers' compensation, third-party administration, group health providers, or at the vendor level (e.g., a free-standing entity that provides case management and utilization review services). There can be a telephonic case management component within acute-care settings, including discharge planning and social work referral. Telephonic case managers handle short-term and long-term disabilities. Home healthcare providers may even have a telephonic component in addition to services delivered in person.


To practice telephonic case management effectively and efficiently requires a commitment and adherence to best practices. One needs to be objective in one's approach and in all documentation. Case management requires clear communication, a strong commitment to diversity, inclusion, and multiculturalism, and adherence to the highest ethical and professional standards.


Best practices for operating telephonically are grounded in the same principles of excellence in case management, no matter where or how it is practiced. We are, first and foremost, patient advocates providing access to the right care and treatment in the right way at the right time.


Practicing case management telephonically is intended to drive cost-savings and increase overall efficiency in the delivery of services; this typically brings with it a larger case load. This is not a problem for the telephonic case manager who understands when it is time to reach out to professionals in the field to provide in-person assessment, to deliver care, treatment, or other services one-on-one. In a workers' compensation case, this may mean asking a vocational professional to assess a worksite, a home healthcare nurse to look at a wound or make an assessment of the patient's home environment, or a social worker to assist in financial concerns for the individual or family.


The field professional's ethical responsibility is not only to deliver the services required in a timely and responsive fashion but also to keep the telephonic case manager informed of any change in the individual's condition, behavioral health, environmental issues, or any other concerns.


I hold a strong personal belief that it is critically important for case managers to be vigilant in their clinical competence. When operating telephonically, it is easy for the case manager to become complacent about delivery of care. Without the in-person contact, the case manager knows he or she is not expected to do a particular procedure or be responsible for the hands-on care. Nonetheless, as clinicians, we need to stay current in emerging medical trends, experimental and investigational procedures/treatments, as well as advancements and new technologies across disciplines. Sound clinical decisions are aligned with evidence-based medical practice.


Regardless of practice setting or discipline, case managers must orient themselves to outcomes, including clinical, financial, and the satisfaction of the individual, family, or payor. These outcomes are interrelated, raising the case manager's awareness of what comprises effective practice. Spending money for a treatment now may diminish the financial savings in the short term, but the improvement in clinical outcome will result in better financial results in the future by avoiding costly complications or repeat hospitalizations.


As telephonic case managers, we orient to these results. The efficiency of providing services by phone should translate into appropriate, medically sound care for the client, as well as a cost savings for all involved. After all, an individual with a complex or catastrophic health issue, who has a $1 million lifetime maximum health benefit, needs to conserve spending, while getting the best care and treatment possible. A telephonic case manager, acting within best practices, can and will contribute positively to that outcome.


Outcomes guide our practice as stewards of healthcare resources. At all times, as advocates, we must keep the patient's best interests in mind. Whether we deal with clients face-to-face or we are a voice on the phone, the case manager is an advocate-first, last, and always.