How case managers can bridge gap between patients, providersIn the business world, team building and collaboration increases a company’s flexibility, productivity, and employee retention. Many of the same benefits apply to healthcare settings, where collaboration between patients and providers can improve patient outcomes, boost patient and provider satisfaction, and enhance the overall performance of the health system.
Case managers strive to engage patients and providers in collaborative planning so that patients may achieve successful outcomes and health systems and providers receive appropriate recognition and reimbursement.
A major task for case managers in hospital or health plan settings is helping patients manage chronic illnesses. While the details may depend on the illness and the patient’s age, collaboration between service providers and patients is a fundamental component to effectively managing chronic disease.
A collaborative plan of care for hospitalized or community-based patients/clients involves:
- Patient-centered focus
- Family and caregiver support
- An interdisciplinary approach
- Focus on transitions from hospital to the community
- Bridging health, social and mental health services
- Employing a flexible plan of care
Assess Patient and Provider Willingness
Before plunging into developing a care plan that takes a patient from hospitalization into the community and through months of managing a chronic condition, a case manager must first assess the ability and willingness of the provider and patient to engage collaboratively. In some cases, it may be necessary for the case manager to be the mediator, translating the desired health care plan from the provider into structured tasks and strategies the patient can execute outside the hospital system.
Case managers are adept at assessing social situations, a highly valued skill in this circumstance. Gathering data about the family and community where a hospitalized patient may be discharged is essential to understanding the resources the client may have available. Much of this assessment data is subjective as clients talk about their needs, feelings and perspectives concerning their chronic illness and their current living situations.
Assessing the willingness of a healthcare provider to work collaboratively with their patient is often slightly easier and may be much more direct. In all cases, it is the case manager who shoulders the burden of understanding the biases and needs of the healthcare provider and the patient to ensure an effective healthcare plan is developed.
Create a Customized Care Plan
Each plan must be customized to the patients’ needs as they present in a hospital setting, community or a residential care setting. Customizing these plans often requires thinking slightly outside of the box in order to engage resources that may not be readily apparent or may not have been used in the past.
For instance, requesting help from a pharmaceutical company to access necessary medical equipment for a diabetic patient may be an easy resource that’s frequently used. However, many communities also have faith-based or community-based social programs willing to assist patients with physical, financial and mental health needs.
Customizing a plan may require a greater depth of knowledge of the patient’s community than is acquired through the usual sources. Thinking outside the box may require the case manager to contact local churches, community social workers and local food banks to determine the types of resources that may be available.
Tailor Education to Each Patient
While not specifically a factor in developing a collaborative plan of care, it is crucial your patients understand the plan you develop with them so it is executed properly and the potential for a successful outcome increases. This requires an understanding of the patients’ cultural environment, ability to understand instructions, and ability to read.
According to the 2014 U.S. Census Bureau, 21 percent of working-age adults lack a high school diploma and 19 percent cannot read a newspaper or complete a job application. This information is significant as many times healthcare instructions are sent with the patient in writing. Part of a case manager’s assessment is to determine the client’s literacy. Education can be delivered through auditory files for those who are unable to read.
Be Ready to Make Adjustments
Hospitalization or residential treatment is a challenging time for patients and families. It is often full of physical, emotional and financial stressors, in addition to the many decisions required to coordinate care and open discussion about future plans.
The success of any care plan must be evaluated to determine if a change is necessary to achieve successful results. Follow up sometimes begins within days after the plan has been implemented. The case manager must be ready and willing to work collaboratively with healthcare providers who may not understand the challenges and needs their patients face after discharge including adult day services, meals, nursing support or supervision.
Additionally, the case manager must work to engage the patient with the healthcare system in order to ensure the plan can and will be executed and the patient’s rights, feelings and beliefs are understood, heard and integrated. Only through a process of collaboration do clients enjoy a greater rate of successful outcomes.
Valdellon, L, (June 27, 2017) 11 Key business benefits of team collaboration. Wrike Solutions
Von Korff, M., Glasgow, R., Sharpe, M., (2002) Organizing care for chronic illness. The BMJ, 325:92
Strauss, V., (November 1, 2016) Hiding in plain sight: the adult literacy crisis. The Washington Post