BY, BSN, RN, CCM, BCPA
We are surrounded by numbers, and the SARS-CoV-2 pandemic has made even those of us who are not typically “numbers people” look closely at data, trends and similar numbers-driven information. For some time, we have had the advantage of data analytics, artificial intelligence and a plethora of algorithms to assist case managers in identifying individual clients and populations who may benefit from case management services. However, we must remember that, as case managers, we have the duty to take those numbers and add the “human touch,” to remember that each number represents a person, and that case management has the potential to significantly affect numbers, outcomes, statistics and satisfaction scores.
As case managers, we are obligated to consider the uniqueness of each and every one of our clients and to customize our case management plans to meet their specific needs. While we certainly must follow ethical guidelines and up-to-date case management standards of practice, it’s best to avoid “cookie cutter” approaches and instead ensure that the clients entrusted to our case management services are provided with best-in-class interventions that are focused on each individual’s needs and wants, the essence of the case management plan of care.
This is not to say that risk management programs and initiatives aimed at preventing adverse events, such as falls or pneumonia, are not extremely valuable and effective. In fact, they are necessary elements in terms of risk management, quality assurance and compliance. Using these types of programs as the basis for “digging deeper” is one of the key elements of the case management process. Case managers must also be proactive in identifying clients well before they appear on “at risk” reports, with the goals of preventing additional adverse events and optimizing our clients’ physical, psychological and holistic health.
To clarify this point, let’s take a look at a fictitious case review regarding a client we will refer to as Mrs. Smith, an 85-year-old who resides in an assisted living community. She has multiple comorbidities, including diabetes, hypertension and asthma. She utilizes a front-wheeled walker independently for ambulation. She is alert and sociable with no noted cognitive impairment. Her most recent assessment reveals a history of three falls in the past two weeks which have necessitated trips to the local emergency room to assess her for injuries. Fortunately, she does not sustain injuries and is cleared to return to the assisted living community. Following each incident, she improves with the help of rehabilitation services and regains the ability to independently utilize her walker again. A comprehensive medication review is completed by her primary care physician, who opines that no changes are necessary. Her chronic conditions are noted to be “under good control,” and she does not display any cognitive changes.
Appropriately, Mrs. Smith is included in a database of residents who are at high risk for falls, and the facility’s fall prevention program is initiated. Additionally, she is prescribed a longer-term physical therapy program for strengthening and education regarding safe ambulation with the wheeled walker. She progresses well in this program and is discharged. However, she continues to experience falls and then cycles back through the fall prevention program and reassessments. Mrs. Smith’s case pops up on a risk management report and she is referred for case management services.
Kathy, Mrs. Smith’s case manager, follows the appropriate steps of case management as she begins to work with Mrs. Smith and her family, who resides close by and is very supportive. During her comprehensive case management assessment, Kathy is informed by Mrs. Smith that she just moved into the assisted living community 10 weeks ago and she feels like she is still getting settled in. She admits to feeling overwhelmed and mildly depressed, stating that she “puts on a happy face” because she does not want to seem like a “negative newbie.” Additionally, Mrs. Smith discusses that her native language is Spanish and that, although she is fairly fluent in English, she sometimes has a difficult time following a conversation when it is stated in English and in a rapid manner. She asks Kathy why everyone “talks so fast,” and she asks if any staff members in the facility are fluent in Spanish. Kathy thanks Mrs. Smith for sharing her concerns and assures her that she will assist her in a prompt and thorough manner.
Kathy immediately pulls together the members of the interdisciplinary team for an in-depth case review and to create a case management plan that encompasses all pertinent issues and needs, including the results of her comprehensive case management assessment, pertinent social determinants of health, language barriers, risk scores and the reasoning behind them, preventative measures that are in place and those that would be most appropriate at this time. Mrs. Smith and her family are active participants in this meeting, in agreement with the plan and pleased that case management services are in place.
Mrs. Smith is offered language interpretation services and, whenever possible, caregivers who are Spanish speaking and can assist her as needed. She is provided with visual prompts and reminders in her room, which she states are very helpful to her. Additionally, although she is independent with her walker, she is encouraged to request standby assistance when moving around her room and in the community, at least until her level of confidence is boosted. She wholeheartedly agrees with this suggestion and does well. As a result of this individualized and comprehensive case management approach, Mrs. Smith does not have additional incidents of falling, becomes more comfortable and self-assured in her new home, and is communicating more and asking for assistance when needed. She and her family are pleased with her progress and verbalize that they are confident that she will continue to progress well. Additionally, as Mrs. Smith continues to settle in, she has become more involved in the social activities offered at the assisted living community including group exercise classes and card games with her new friends.
Adjusting to new surroundings, particularly at an advanced age, can have a profound effect on individuals and may cause depression, anxiety, fear of isolation and increased distractibility. As a result, the risk of disorientation and falls becomes an important area of focus in terms of proactive planning. Early referrals to the case management team are essential so that the case manager can identify and promptly address such risks and involve the staff, client and family in delineating appropriate interventions that will mitigate those risks and achieve high levels of client and family satisfaction. In Mrs. Smith’s situation, a case management referral program that identified her as “at risk” could have been instrumental in preventing her recurring falls. That is, instead of having her name appearing on an “at risk” report following several falls, Mrs. Smith would have benefited from a comprehensive case management assessment and risk identification program immediately following the date she moved into the assisted living community.
In summary, as case managers, we are in a unique position to take the data that is presented to us and dig deep to the root causes of issues so that optimal outcomes are achieved and our clients are as safe and complication-free as possible. That is the essence of case management and why we do what we do each and every day.