1. Moran, Peter MSN, RN,C, CCM
  2. Owen, Mindy RN, CRRN, CCM

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I am often asked why I am a case manager and what it is I do for a living. Sometimes I wonder the same thing myself. Recently I had the opportunity to run into the daughter of a patient I had met several years ago in the emergency department (ED). Mary was a 92-year-old, stubbornly independent woman who had presented to the ED after falling and suffering L3-L4 compression fractures. I had been asked to meet with Mary and her two daughters, who had told the nursing staff Mary could no longer live by herself. First, I had the opportunity to meet alone with her two daughters, Dottie and Betty. Mary's oldest daughter worked at the same hospital and had asked that a case manager get involved. The daughters had been trying to convince Mary to move in with one of them to no avail; she had lived in her home since she was born and did not want to move.


Mary had been failing at home for some time and had refused all community services. Her safety was increasingly becoming as issue as she became more forgetful. They had concerns about not taking her medications correctly and had been falling. Mary had six steps at the entrance to her house and her bedroom and bathroom were on the second floor. Dottie and Betty were quite upset, as they felt guilty that they had not forced Mary to move earlier. Now she was in the hospital with a "fractured spine." They told me how Mary had raised them and always put herself out for them. They talked about this woman who was fiercely independent, caring, and the family matriarch. I asked them if they would give me some time alone with Mary when she returned from her radiographic examination. I wanted to speak to her and understand what it was that Mary wanted. We could then all talk together.


I introduced myself to Mary when she returned from her tests and requested permission to speak with her. I explained that I was a case manager in the ED and my job was to interview patients to see how they were managing at home. Mary broke down in tears and told me she managed just fine. She told me her kids just wanted to put her in a nursing home and she was not going to any nursing home.


I explored with Mary what it was she would need to be able to do to get home safely. With her back injury, she was not able to ambulate and needed physical therapy, occupational therapy, and better pain control in order for her to move back home. She agreed. She told me that she worried about being a burden to her family, they had enough of their own problems, and she did not need to be worrying about her. I explained they loved her and wanted to support her in her decision and also had legitimate concerns for her safety. Mary agreed she was not able to manage by herself now and agreed to go to a short-term hospital-level rehabilitative admission.


I invited her daughters back in the room and met with them as a group. I was so impressed by the love between them and asked their permission share my impression-that in trying to protect and take care of each other, they were creating barriers, which honestly did not need to exist. Mary agreed to go for rehabilitation. It was determined that all would see how Mary did at rehabilitation before deciding the next step. Dottie explained she would love to have Mary live with her and was willing to set up a mother-daughter type apartment that would allow Mary some independence and also alleviate the family's concern that she was alone too much. Mary agreed to allow people in to assist her when she was discharged from the rehabilitation-something she had always refused to do in the past-and agreed to consider living with Dottie if the rehabilitation experts felt she should not go home alone. The stipulation was that she would pay the cost of any remodeling.


Mary was discharged to the rehabilitation and I lost touch until I ran into the family that day. She told me Mary had done well and was living in the mother-daughter apartment in Dottie's house. Dottie began tearing up and gave me a big hug and said those two most magical words: Thank you. Thank you for getting mom to come to my house and thank you for your assistance in helping us get through those rough times; without you, we probably would have forced mom into a nursing home.


Sometimes our role is to bring members of the hospital team and family together to reach consensus. In this case, it was a matter of acknowledging and validating the love and concerns within this family unit and assisting them to reach compromises in which they all felt heard. When it comes down to it, folks, I guess it is these types of moments that best remind me why I am a case manager. I did not really remember Mary and Dottie and honestly never considered the impact of what, to me, was a routine intervention for the people we serve. But we matter!! Thanks to each and everyone of you for the work you do.


The intent of this column is meant to speak to the heart of case management: our joys, our struggles, and our lessons learned. Please send your thoughts and ideas to us so we may include them in future articles.