The 17 year old, Case Management Society of America (CMSA), has announced the celebration of National Case Management Week.  This special week-long event seeks to unify case management professionals, educate the public about case management, and increase awareness and recognition of the significant contributions case managers make the quality healthcare for patients, healthcare providers, and payers.  This week is celebrated nationally during the second full week of October each year.

CMSA is an international organization of case managers and healthcare professionals, committed to promoting the growth and value of case management, and to support the evolving needs of the case management professional.  Founded in 1990, CMSA now has over 11,000 members and over 70 affiliated and pending chapters. I am one such member and proud to be a part of the Little Rock Chapter.

For those who are unfamiliar, Case Management is a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individuals heath needs through communication and available resources to promote quality cost-effective outcomes.  My case management practice is primarily associated with workers compensation clients.  Injured workers need prompt assistance in finding the appropriate healthcare provider who will diagnose them quickly and provide the treatment plan to help get them back on their feet and productive again.  My job is to first assess the situation which includes not only the injury itself, but also the claimant’s situation at home, emotionally, mentally, physically, socially, etc.  The next step involves locating the provider, arranging the appointments; all while educating those involved.  The plan is ever changing as the situation changes.  I am advocating for my patients to help them get their needs met all the while working to save the insurance carrier money by preventing unnecessary testing, negotiating reduced rates for services, limiting loss time wages, and eliminating waste.

Establishing a nationally recognized Case Management Week is vitally important as the field of case management becomes an increasingly recognized as a strategy of great significance across the continuum of care.  Not only does case management support patients and their families in navigating the healthcare system, it decreases the fragmentation of services, encourages health team communication, and contributes significantly to patient safety, quality of life, and cost-effective management of limited resources.  It should be recognized by the healthcare industry as a crucial element of giving.

If you wish to learn more about Case Management or CMSA, contact Cheri Lattimer, Executive Director or visit www.cmsa.org.  The association headquarters are located right here in Arkansas at 6301 Ranch Drive, Little Rock, AR 72223.  501-225-2229

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I am so proud to be a nurse case manager.  I have worked in this industry since 1999 and became certified in 2003.  October 10-16, 2010 marks National Case Management Week, recognizing the contributions and commitments case managers make and educating the public about the significant work we perform. When employed by an agency or hospital, activities typically include banquets and recognition dinners, state and city proclamations, continuing education seminars, and other community events. Case Managers are typically honored with gifts, dinners, and flowers coworkers such as doctors and administrators, and patients who want to show their appreciation.

As an independent case manager, I do not get to participate in such activities, but I can still celebrate.  Here are a few ways each of us can participate in National Case Management Week.

• Tell 10 other professionals you are a case manager
• Offer to speak at community events on case management
• Wear your CMSA Member Pin
• Promote case management by sponsoring or volunteering at a health fair, preventive screening or organizing services in your community
• Host a reception in your community
• Host a professional seminar for health professionals in your community
• Highlight a different case management practice setting each day of the special week in your newsletter or blog
• Encourage your mayor, county executive or governor to issue a local proclamation establishing October 10-1th as National Case Management Week
• Invite a politician to accompany a case manager at their place of business for a day
• Decorate with banners, posters, or flyers
• Publish newsletters focusing on CM week
• Speak to nursing organizations about case management careers
• Create a publication of case management stories
• Write a letter to your local paper
• Contact radio and TV stations to let them know about CM week
• Write a guest editorial to newspapers, journals or magazines regarding the positive impact of case management
• Distribute a press release announcing CM week

I am committing to several of these activities this year.  (I just completed one by posting this!)  I am glad I have an opportunity to impact my patient’s lives everyday.  The very things that seem so simple to me, make a big difference in the lives of others.  I just hope I can continue this for many years to come.

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I recently read an article by Chris Moranda in The Rehabilitation Professional on getting managers to buy-in to the concept of return to work and its benefits.  He states the best measure of the effectiveness of any case management program is job placement which is accomplished through various tools such as…

• up-to-date assessments of job descriptions and analysis with essential functions
• ergonomic evaluations
• reasonable accommodation assessments including identifying adaptive equipment.

Most importantly is the understanding and support of managers.  Though managers and supervisors may be highly trained there remains a great need for awareness of the requirements of the Americans with Disabilities Act (ADA) and the recent ADA Amendments.

In my role as a case manager I can further the company’s understanding to move managers and supervisors beyond an attitude of compliance to one of being a champion for those they represent.  In order to accomplish this, the case manager must begin by forming relationships with those employers to gain their trust, hear their concerns and help pursue solutions.  Creativity is the key.  A case manager and manager working together can often make adaptations that benefit everyone.

One goal for case managers is to support the employer to become more comfortable in taking back an employee on light duty restrictions through a transitional work duty program.  A manger who sees how accommodations work will more likely be willing in the future to consider hiring other people with restrictions and disabilities.

A case manager can forge these relationships with the human resource person.  Through this relationship the case manager could attend managers meetings as a consultant to represent and inform about transitional work programs, the ADA and demystify reasonable accommodations.

With this in mind the case manager must understand the company’s attitude regarding return-to-work (RTW).  If the employer is only focused on production the reduced work capacity of the individual will make fora difficult course.  The company’s goal should be to champion employees on the job and working.  If the concern is focused on decreased productivity, one option would be to have the patient to function as an extra staff and not impact the productivity of the department or even move them to a non-production position temporarily.  The most important matter for managers to understand is the value the employee brings to the job through knowledge and experience.

As both a case manager and an ergonomics assessment specialist, VP Medical Consulting can provide employers with the assistance they need to develop cost effective transitional duty programs.  This results in a win-win situation for the employer, the injured worker, and the carrier.  Let us help you get started today.

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Working as a case manager in the area of workers compensation, I heard the term life care planner, but didn’t really understand the term.  Later, while working as a legal nurse consultant, I began to hear the term more frequently.  Finally an attorney client mentioned that he needed a new life care planner and my ears finally perked up.  If my client needed it, perhaps I needed to find out just exactly what this was all about.

I am proud to say that I have been providing nurse life care planning services for several years.  It was a great move for me and something I enjoy.  I have people ask me frequently to explain life care planning and felt it was time for a post to address some of these frequently asked questions.

1.  What exactly is a life care plan?

A life care plan is just like any other care plan we would write as a nurse only it covers the individual for life.  It is dynamic just as our bedside care plans change as our patient’s condition changes.  The plan is based on the author’s standards of practice coupled with nursing assessment, analysis of the medical records and other data, as well as research and collaboration with providers.  The plan provides an organized and concise outline of the current and future needs along with the costs of those needs.  Careful consideration is given to the patient’s goals, needs and interests as well as their geographic area and the types of care to be found in the area.

2.  How does this plan benefit the patient?

The life care plan is a tool.  It is used for education, budgeting, case management, rehabilitation, and has application both in and outside of the judicial system.

3.  What is the role of the nurse life care planner in a litigated case?

The role is one of an educator rather than an advocate.  The author must maintain objectivity and base his or her recommendations on the medical records, assessment and interview as well as the history of care.  The author should is to set forth rehabilitation goals that are attainable, which include how and when services should be provided, how to implement the plan and it must be clearly communicated.  The author of the plan is considered an expert in life care planning and will be asked to testify as such to explain the plan and how he or she derived at the recommendations put forth in the plan.

4. What is the difference in a plan written for the defense versus one written for the plaintiff?

There are no differences.  A life care plan is to address the needs of the individual and should be created in a systematic approach.  The life care plans are individualized to the patient, but should not vary based on the requesting attorney.  It is not unusual to be prevented from in home assessment and interview when writing a plan for the defense, however that does not mean that the approach to the plan is any different.  This only means that some portions of the standard approach may be missing.

5.  What do you do about collateral funding sources when writing the plan?

Life Care Plans are to be needs based rather than funding based.  If the item is needed, it is included in the plan regardless of funding for that particular item(s).  Needs and the associated recommendations are not to be restricted to only those items covered by insurance.  Costs associated with the care recommendations are cited according to the prevailing charges within the community in which the patient resides.  The plan covers the individual’s life expectancy and funding sources change and even disappear.

6.  Can I become certified as a nurse life care planner?

YES!  There is a Certified Nurse Life Care Planner certification board which certifies only nurses as life care planners (CNLCP).  They provide three routes for one to become certified and information about each can be found on their website.  There is also a certification (CLCP), not specific to nurses, which is granted by the Commission on Health Care Certification.

7.  I am interested!  Where can I find more information?

The American Association of Nurse Life Care Planners is the association for nurses in this exciting field.  The have a website that includes the mission of nurse life care planners, member lists, conference information, and resources.  The annual conference is an excellent way to obtain additional information as well as to network with other like minded individuals.  The International Association of Rehabilitation Professionals also provides information for life care planners and includes a section specific to life care planning entitled International Academy of Life Care Planners.  This association hosts multiple educational events throughout the year.  The Care Planner Network is dedicated to the community of life care planners and hosts a directory as well as a forum.

If all of this sounds interesting, but you are afraid to take the plunge, join me on October 8th in Boston for a conference on nurse consultants in business.  We will discuss how to get started, marketing, technology, the logistics of doing business, and much more.  Then, if you stay for another day or so, you will meet a host of individuals in all stages of their business.  Learn the pros and cons.  Find your local guru.  Surround yourself with support and encouragement.  You can do it!

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Lineman, Shawn Spiwak’s was working when he was hit by 7,200 volts of electricity by what was thought to have been a dead wire. His elbow had brushed against the line when electricity ran through his body, sparks flying from his chest.  He fell backwards and was left dangling upside down from his safety harness.  His arm had been burned through and through.  There were entry and exit points left by the electricity.  He was severely burned and eventually lost his right leg at the hip and his right arm and shoulder well into his clavicle.

Electrical injuries often lead to amputation as well as a multitude of other problems which result with the nervous system of the body is short circuited.  The electricity literally burns from the inside out.  What you see on the outside is far worse on the inside.  Treating a patient with electrical burns is very complex and usually have a host of other issues which come up during the treatment.  The body is unable to regulate temperature.  The dead tissue (eschar) has to be cut away daily.  Typically the patient is placed on a ventilator and oftentimes placed into a medical coma.  Feeding tubes are placed to help provide the increased protein needed for wound healing.

These injuries leave an individual with many deficits.  Mr. Spiwak’s walked with a limp secondary to the prosthetic limb.  He is stared out and children often ask about his prosthesis to which he replies, “robot parts”.  Like others with severe injuries, Mr. Spiwak notes it takes more time to do everything.  Simple things like buttoning your clothes, putting on your shoes, opening a bottle, brushing your teeth; all require additional effort and sometimes assistive devices in order to complete the tasks.  Scar management is life long which requires multiple surgeries, compressive devices, and therapy.

Electrical amputation is one of the many topics of an upcoming Nurse Life Care Planning conference scheduled for October 2010.  As a Nurse Life Care Planner and Nurse Case Manager, I am often called on to coordinate care for or develop a life care plan for persons suffering amputation injuries.  If you want to learn more about this devastating injury, please join us in Boston on October 8-110, 2010.

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I contacted an attorney client this week to let him know that a potential care management client might be calling to speak with him about my work.  I asked that he be brutally honest and not embellish.  He shot back an email that stated he would just tell her that I was too busy, stressed out, and always takes on too much.  (Now, I must explain that this was said with tongue in cheek and he later stated he would never hesitate to recommend my work and never worried about his reputation being on the line for said recommendation.)  The problem; he was pretty spot on.

Ellen Fink-Samnick, a case manager and Commissioner for Case Manager Certification, recently published an article in Care Manager entitled Being in a Caring Profession Doesn’t Mean We Can’t-and Shouldn’t-Care for Ourselves.  She explained that this syndrome of fatigue, stress, and burn out is an occupational hazard that comes with being a health care services professional.  I couldn’t agree more.   We must advocate for ourselves just as we advocate for others.

Ms. Samnick feels that if we cannot give our own needs priority or at least equal attention that we give to our clients and patients we threaten the quality of case management.  A good friend once told me that if I don’t set my priorities someone would set them for me.  Oh so true!  But also a tough concept as a small business owner.

Avoiding burnout requires a different prescription for different people.  During one such period of burnout, my father became critically ill with renal cell carcinoma.  I began to provide case management services for him just as I would one of my other patients.  After seeing the tremendous relief of my family secondary to what I was doing, it renewed my love for what I do. Some nurses facing stress and fatigue may need to spend some time doing other things they wish to accomplish such as writing or speaking or taking a class.  Others may need to take a yoga class or get a pedicure or massage.

Some of us (me included) need to be reminded of this often.  Being a small business owner makes setting priorities (especially for self-care) extremely difficult.  I often feel that if I were to turn down a job when overwhelmed, I will not receive another.  As I get older, and the business has a proven track record, I see some progress in caring for myself.  Having new grandbabies on the way may help push me to take advantage of more downtime as well.  I can’t think of a more relaxing time away from work than rocking an infant.

Are you battling stress and burnout.  What do you do to care for yourself?

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A critical aspect of any catastrophic injury lawsuit involves the determination of the injured party’s future medical care. The life care plan is a tool that is written by a professional and often used to specifically identify all of the future care (medical and non-medical) needs of the injured party. The life care plan addresses the costs and frequency of the needed goods and services over a lifetime. It will project the needed equipment, replacement scheduled and maintenance.

In many cases attendant care is needed. The plan will determine how many hours per day care is anticipated and what level of individual is needed to provide the care. Some care may be provided by unskilled labor while other care requires expertise of a licensed individual. Still other care could be calculated to provide respite for the family care givers.

Another large area in injury cases (and particularly those cases which involve children) are the calculations the therapy needs. Therapy needs may consist of physical therapy, speech therapy, occupational therapy, and recreational therapy and may last a lifetime.

A life care plan will also address the number of physician visits required throughout the injured party’s life, any adaptive equipment he or she may require in and around the home, home modifications, transportation needs, diagnostic testing, and often much more. It is common for the nurse life care planner to meet with the injured party’s family in their home to assess the extent of the needs. The plan is a collaborative effort that involves the life care planner as well as the multiple medical professionals involved in the medical care.

Nurses are well suited to this field of life care planning. Beginning in nursing school, nurses learned how to develop a nursing care plan. This same nursing care plan is the essence of Nurse Life Care Planning. The Nurse Life Care Planner initiates the nursing process with a nursing assessment and using a holistic approach to encompass the client, their support system, their environment, and their individual needs related to the injury or illness.

The nursing assessment is based on collecting subjective and objective data from observations, examinations, interviews and written records. The data may include symptoms, growth and development, family health history, information collected by other health team members, culture and religion, ability to perform activities of daily living, educational and vocational background, patterns of coping and interacting, and environmental factors. The Nurse Life Care Plan is intended to follow the client through his or her lifetime to ensure funds will be available to properly care for the client.

Nurse Life Care Planning is an extension of case management where the nurse has learned to perform an assessment, formulate a plan of care in collaboration with the health care team, facilitate medical needs and negotiate costs related to care. Other specialties of nursing that are also well suited to this area include rehabilitation, discharge planning, utilization review nurses and even home health nurses.

The American Association of Nurse Life Care Planners (AANLCP) was established to promote a professional practice within nurse life care planning. To learn more about this exciting field of nursing, I encourage you to contact the association and consider becoming a member.

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In both of my roles, as a nurse life care planner and nurse case manager, I have frequent exposure to individuals suffering from chronic pain, either as a result of a traumatic injury or due to disease progression and aging.  In reading this article, I had to wonder what other methods of pain management, outside of prescription painkillers, were being employed in these tragic cases.

In my practice I examine all of the issues involved in cause and treatment of the patient’s chronic pain Many times, a more holistic approach is the most effective and carries less risk of addiction and potential overdose.

Questions I ask in these cases include, but are not limited to: What effects acupuncture or other non-pharmacological treatments might have on relieving some of the pain? Would the patient benefit from psychotherapy to help with issues and depression surrounding his or her condition?  Has the person been trained in any breathing and relaxation or other biofeedback techniques?

These are just a few of the considerations that a nurse case manager might evaluate as alternatives.  These considerations should be evaluated and possibly included in the life care plan to help minimize use of potentially addictive medications and to ensure maximum quality of life for these patients.

What are some other alternatives for the management of chronic pain?  What has worked for you?

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Sam Albrecht, Executive Director of the Commission for Case Manager Certification, presented testimony on December 3 on the important role nurse case/care managers play today and in the future of health care system.  All case managers should review this paper which documents the current and future role case managers have in ensuring consumers of health care receive safe, quality, evidence-based care regardless of setting.  You can review the paper in its entirety here.

As outlined in his paper, Mr. Albrecht shares a comparison of nursing and case management processes which reveal the following commonalities:

• The nursing process of assessment equates to the case management process of case finding/screening and intake; assessing the patient’s needs 
• The nursing process of diagnosis equates to the case management process of identifying actual/potential problems 
•  The nursing process of planning equates to the case management process of interdisciplinary case conferencing; establishing goals of treatment and expected outcomes of care; developing/individualizing the case management plan 
•  The nursing process of implementation equates to the case management process of implementing the case management plan/interdisciplinary plan of care; facilitating/coordinating patient care activities 
•  The nursing process of evaluation equates to the case management process of monitoring the delivery of patient care services; evaluating outcomes of care/patient responses to treatment; discharge/disposition; repeating the case management process. (Cesta, Tahan, 1998)

For those unfamiliar with the CCMC-Commission for Case Manager Certification, the commission began in 1992 and has certified more than 35,000 case managers.  I am one of them.  Not only do we provide access to appropriate healthcare services and promote patient impowerment.  You can learn more about the certification process on the CCMC website.

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This week I ran across a posting by a Dr. Luks, a physician I follow on Twitter.  The information was originally written by another physician blogger.  Dr. Rob who writes Musings of a Distractible Mind posted this and it ran in the NY Time Health issue.  I was compelled to include this information here as well.

Rule 1: They don’t want to be at your office.

It may seem odd to patients, but most doctors forget that going to the doctor is generally unnerving. We work there, and being in a doctor’s office is normal to us. Not so with most patients. The spotlight is on them and their health. They stand on the scale, undress, tell intimate things about their lives, confess errors, are poked, prodded, shot with needles, lectured at, and then billed for the whole thing….There is always an underlying fear and self-consciousness that pervades when a person is sitting on the exam table. The best thing to do in response to that is to show compassion.

Rule 2: They have a reason to be at your office.

They don’t come to the office to waste the doctor’s time. Yet early in my training I was incredulous at the reasons some of my patients were coming to see the doctor. Why come in for a headache? Why come in for a cold?…It took me being in my own practice (and trying to keep my business going) to realize that there is (almost) always an underlying reason for a patient to come in. Sometimes that reason is simple: they have terrible pain that needs to be treated. Other times, however, the reason is more subtle. When a person comes to my office with enlarged lymph nodes, for example, the real reason they are coming in is that they are afraid it is cancer. If a person has chest pains, they are afraid it is their heart. On every visit I try to identify the real reason (or the real fear) that brings them to see me. I don’t end the visit until I have addressed that reason.

Rule 3: They feel what they feel.

Patients will often tell me their symptoms in a very apologetic tone. They seem to think that they have to come to me with the “right” set of symptoms, and not having those symptoms is their fault. Sometimes those symptoms make no sense to me at all, and I am tempted to dismiss or ignore them. But as a physician, you have to trust your patient….Yes, some may exaggerate what they feel out of anxiety or out of fear that you won’t hear them for lesser symptoms, but then your job is to uncover the anxiety, not ignore the complaint. I have heard from many patients that their doctor “did not believe” their complaints because they did not make sense. If you don’t trust them, why should they trust you?

Rule 4: They don’t want to look stupid.

People are often worried that they are over-reacting. They wonder what I must think for a person to come to the office with that symptom. This is especially true of parents bringing their children in. Nobody wants to be “that mother that over-reacts to everything.” In response to this, I try to specifically say, “I am glad you came to the office for this because…” or “Yeah, I can see how that worried you because it could be….”

Rule 5: They pay for a plan.

What do people pay for when they come to the medical office? They pay for opinion, yes. They pay for knowledge as well. But what they really pay for is a plan of action….They want to know what is going to be done to help. I try and give a plan, either verbal or written, to each patient that walks out of the exam room. What medications are given and why? What medications are to be stopped? What tests are ordered and what will the results mean? When is the next appointment? What should they call for if they have problems? The better I can answer these questions, the more confidently the patient will walk out of the exam room. The days of paternalistic medicine are over – no handing a prescription and just saying “take it.” Patients should know why they are putting things in their body.

Rule 6: The visit is about them.

With all of the stresses in a doctor’s office, I get tempted to complain about things. Who better to complain to than someone who feels much the same way? But patients are paying for you to take care of their problems, not the reverse. I keep my personal gripes or frustrations to myself as much as possible.

As a Registered Nurse, and more specifically as a case manager, I feel that if physicians would take the time to study these six simple rules we would see a far greater satisfaction with our healthcare system.  So much of my job is filling in the blanks left by the physicians.  I realize there is not enough time to spend with our patients.  The current payment system for medical services does not allow the face-to-face time that our patients need and deserve.  My job largely came out of this need.

Every day I spend countless hours listening to patients, helping them to determine if their symptoms warrant urgent treatment, explaining medication usage and side effects, aleviating fears, sharing alternative treatment options, and just being there for them.  I love the patient advocacy part of my job, but not everyone has access to a nurse when needed.  The average patient goes to their primary care doctor for these very same things.  Even when I attend an appointment with my client, I find myself having to reiterate the entire visit because they did not have time to digest the information due to the very quick face-to-face interaction.

It is time our doctors realize what a huge difference they can make even in the ten minutes they spend with their patients.  Putting yourself in the place of the patient should help alleviate any attitude you might have.  Secondly providing time for questions.  Make sure when the patient leaves they have a written plan of action that they can review after they leave the office.  Provide an avenue for questions that arise only after they leave your office.  It would make my job a lot easier. 

Do you have any other suggestions in providing care for our patients?  As a nurse what interactions do you have with patients outside of the doctor’s office?  What recommendations would you make to extend the few minutes one has in front of the physician?

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