BY MARY MCLAUGHLIN DAVIS, DNP, ACNS-BC, NEA-BC
Case managers are expert communicators and understand this is a skill essential to meet the CMSA Standards of Practice and effectively help patients navigate a complex health system (CMSA, 2022). They may meet their patients in person either in the acute or ambulatory care setting. Other case managers practice remotely and establish a relationship with patients via telephone or using other telecommunication tools. These skills honed over time, study and practice provide the basics of practice for case managers.
The case manager sets up a relationship with the patient as the first step in helping that patient to experience the best health possible. It is in the first patient assessment that the case manager finds if the patient can speak English, and if not, makes the accommodations to communicate through an acceptable interpreter. Language differences are one potential barrier in the relationship between the case manager and the patient, and it runs deeper than words alone.
What if as a case manager you had to practice with one hand tied behind your back? International case managers experience a handicap when they enter their practice. They must develop a separate set of tools than they previously used or adapt their tools to meet the needs of the international patient. It is their responsibility to engage the patient and to incorporate their belief system, allowing them to make well-understood healthcare decisions (Mirsa-Herbert, Isaacson, 2012).
I interviewed a case manager for Cleveland Clinic department of Global Patient Services (GPS), to understand the challenges international case managers face. Julie Ziebro-Latarski, RN, BA, BSN, began her nursing career working in acute care and over time sought the ability to spend added time with patients and affect their ability to meet their health goals. The move to case management was a natural evolution, and Julie enjoyed working for a large health plan. She aided patients with understanding medications, getting doctor and other healthcare appointments and counseling on chronic disease. She achieved her case manager certification and began working in the population health space with the carrier. She loved making a difference in patients’ lives. The move to case manager for international patients in GPS provided another challenge for personal and professional growth.
GPS is multifaceted and helps patients with all the details of travel and care before, during and after discharge from acute hospitalization. The team embeds continuous quality improvement in the department with a patient experience lens, like all Cleveland Clinic programs. GPS focuses on patient experience with three main goals: First, building partnerships and advocacy with international patients always with a focus on the patients’ culture. Second, creating evidence-based data to support the process improvement of inpatient experience. Third, collaboration with all Cleveland Clinic teams to communicate the Cleveland Clinic culture of empathy transcending cultures and languages (Cleveland Clinic, 2019).
Julie explained her close working relationship with the GPS account managers, who are the lay navigators between patients, case manager and the interdisciplinary team. Most account managers are from other countries and English is a second language for them. They own a special empathy for this patient population. Julie, as case manager, coordinates care for the patients, working closely with the account managers to ensure translation of all the patient information and communicates it to all providers. She ensures patients understand any new diagnostic and lab work needed for treatment.
Julie described a typical day that consists of tracking all patients at the request of specific embassies, who sponsor the patient’s care, meets newly admitted patients, responds to emails from the different embassies and completes the triage form for embassies requesting necessary patient coverage. She also prepares letters of reparation for patients to ensure they have the necessary equipment and services when it is time to leave. The payers are the patient’s country through the embassies. Patients may also arrange to pay privately. Patients may discharge to temporary housing near Cleveland Clinic, and Julie visits with the patients when they return for follow-up visits in the ambulatory setting. She oversees the proper transportation to meet their medical needs for their return home.
When asked, “What are your biggest challenges?” Julie states communicating with patients in a meaningful way when an interpreter leads all verbal communication. Motivational interviewing is particularly difficult to do with an interpreter. She says reading body language is also not always effective due to the cultural differences in how individuals express themselves in diverse cultures. She learned how to adapt her communication style to the culture of the patient she is seeing and then tailor it to the individual patient.
She cites the challenge of end-of-life care for patients. Recognizing a patient’s pain is essential, as specific cultures promote pain endurance and others support a full manifestation of pain. Treating pain is also varied, and educating patients reluctant to take treatment on how the right use of opioid pain medication will relieve physical and psychological stress is necessary (Givler, Bhatt, Maani-Fogelman, 2019).
Certain cultures believe in providing full care and treatment for patients, even as the medical team recognizes that the patient’s disease state is incurable and insurmountable, that even with maximal medical treatment there is no benefit and continued failure (Givler, Bhatt, Maani-Fogelman, 2019). The interdisciplinary team of medical ethicists, social workers, physicians, nurses and the international case manager meet and collaborate closely with the patient and family to achieve a dignified and peaceful end of life experience. It is critical all case managers know that the myriad of diverse cultural beliefs affect how to help patients in this challenging time (Givler, Bhatt, Maani-Fogelman, 2019). Sometimes this requires the international case manager in conjunction with the patient’s embassy to arrange for quick travel back to the patient’s country because this is particularly important to them.
Julie works closely with the inpatient case managers, who arrange the coordination of care and discharge arrangements made locally prior to the patient returning to their home country. Kathleen Buchanan, BSN, assistant manager for case management, also took part in the interview, and she describes how patients may stay in acute care longer because other countries do not recognize post-acute care such as skilled nursing facilities, acute physical rehabilitation hospitals, long-term acute care hospitals and hospice care. Kathleen appreciates the collaborative relationship she has with Julie and their ability to solve problems as a team.
Kathleen states that not all international patients fall under the dominion of GPS, and she values what she learns from GPS and Julie so she can aid patients who do not have health coverage in the U.S. and help them to recover and return home. Kathleen’s team faces all the barriers Julie and the GPS team face but with the added challenge of not having insurance coverage or the means to access lifesaving services such as dialysis and chemotherapy. Each patient is unique and requires a strategic plan to provide a safe and effective discharge.
Kristine Adams, CNP and associate chief nursing officer of care management, recognized the need to coordinate with a team of teams across the disciplines to implement safe discharges for international patients without resources in the United States. The team includes members from finance, medicine, nursing, care management, legal and ethics. Kristine states that international patients, like all patients, are better off at home, if possible, where they are most comfortable and have benefits they do not have in the U.S.
I asked Julie who her most memorable patient was and why. She recounted how a pediatric patient did not have the outcome her family hoped for and was returning to her home country to die. The child did not speak English and Julie did not have the words to communicate with her. Julie knew she loved Disney princesses, so she sat with her and sang her favorite princess song. Although the situation was sad, this case manager found a meaningful way to convey her empathy, compassion and love for the child and her parents.
References
Cleveland Clinic 2024. https://my.clevelandclinic.org/patients/international
Givler, A., Maani-Fogelman, P., Unison-Pace, W., Thayer, J., & Gaston, G. (2019). The importance of cultural competence in pain and palliative care. StatPearls.
Misra-Hebert, A., Isaacson, H. (2012) Overcoming health care disparities via better cross- cultural communication and health literacy. Cleveland Clinic Journal of Medicine, Vol. 79, No. 2. Feb. p. 127-133
Mary McLaughlin Davis, DNP, NEA-BC, ACNS-BC, CCM, is a Certified Case Manager, clinical nurse specialist and was senior director for case management Cleveland Clinic Main Campus and Akron General Hospital until her retirement in 2022. She is currently a project manager for case management Cleveland Clinic. She served as an executive board member of The Case Management Society of America, from 2013 to 2019 and president from 2016 to 2018.
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