1. Moran, Peter MS, BSN, RN, BC, CCM

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Recently, I have been amazed at the number of encounters I have had in my day-to-day practice where the issue of "lack of time" has been raised. This has been not only in case managers' lives, but, more importantly, in our patients' lives also. In the recent weeks, two of my patients had been diagnosed with advanced sarcomas. In both cases, they were diagnosed in early January; by the end of March, it seemed hospice was imminent. At the same time that the families are trying to get their head and heart around the idea that their loved ones are sick and wondering when they will get better, the providers are recommending hospice.


One 94-year-old woman told me she felt as though none of her doctors ever have time to speak to her. They rush in and out but do not have time to allow her to ask her questions. An 89-year-old woman with dementia presents with complains of new onset hallucinations; is it a progression of dementia or is there an overlay of delirium-and do we have the time to differentiate? If she is not a threat to herself or others, the psychiatric department does not initiate a consult; and if we cannot find a treatable source of the delirium (i.e., a urinary tract infection or pneumonia), she may not meet inpatient criteria for an acute hospital admission. But somewhere, somehow, we need to be able to sort it out. At this point, I am doing my best to determine where-and how-we can sort it out. So little time, so few resources.


Not long ago, my mother had a knee replacement operation. We had done our due diligence and had asked that she be screened for short-term rehabilitation. We identified three rehabilitation facilities and requested that they evaluate her for services, listing our preferences as first choice and third choice. My mother had surgery on a Friday and we were told she would probably be transferred on Monday after her surgery. I received a call from my mother that the case manager had been in to speak to her on Monday and had told her she would be going to a rehabilitation facility that afternoon but not to any of the three facilities the family requested. The mother was told the "chosen" facilities did not have available beds. After the case manager had left the room, the admissions coordinator from one of the preferred facilities came to evaluate my mother and told her the facility did, in fact, have beds. I told my mother to call the case manager back and let her know where she wanted to go, as she is entitled to choose. What happened? Was this another casualty of "lack of time" to do things right?


In my own work environment in a busy emergency department, we have an observation unit where patients are supposed to stay only for 23 hours. They are then either to move to inpatient care or to be discharged. We have a "no diversion" policy, so the emergency department can no longer divert ambulances when they are overextended. Therefore, the pressure is on to swiftly determine whether they should be in observation unit or under inpatient care, and open up beds as quickly as possible. I hear primary care physicians talking about the expectation that they must see so many patients in an hour. I wonder where, in our fragmented healthcare system, we have the necessary time to explore increasingly complex patient problems. The pressure to move people through the continuum is palpable; the driving force appears to be money, rather than quality of care or the patients' best interest.


Technology has allowed us 24/7 access via e-mail, fax, BlackBerry devices, Twitter, and many other modes of communication, but does it create better or more focused communication? Does it divert our attention or assist us in communicating? So much of what we, as case managers do, is based on the relationships we forge with providers, clients, vendors, and colleagues. Over the years I have watched as we have centralized case management services. I have watched as we moved from on-site case managers to telephonic case managers and from individual care plans to generic, disease-specific ones. In my mind, the big question remains-has this improved the case management services we provide? There have been several case management demonstration projects, most of which have failed to demonstrate a positive financial impact from the case management services provided. I am aware of three demonstration projects, which have demonstrated positive outcomes; these all involve the component of direct interaction and coordination between providers, clients, and case managers. In the current economic environment, case managers will continue to feel increased pressure to do more with less. I encourage case managers to continue to advocate for their patients and clients. I encourage you to take the time in order to address concerns and issues and strive to make decisions with the clients' best interest in mind.


Time is a scarce and valuable resource. The next time you feel you do not have the time to follow up with the preferred rehabilitation facility-or hospice facility-consider the time your patient has remaining. It is all about patients and their quality of life[horizontal ellipsis]for whatever time they may have.