Like many nurses, Stacy Szucs and Kim Farr came to work in case management after long and varied careers. They have found it to be a dynamic and growing role that is changing them and their nursing practice.
Case managers offer ongoing support, expertise and coordinated care for patients with complicated health needs. Once a narrowly applied function, case management has become a fully developed area of practice in which professionals manage the social, medical, financial and behavioral issues associated with complex cases, according to the Commission for Case Manager Certification.
"When Pulse first started publishing in 1992, utilization review nurses often served the role of reviewing requested clinical services for coverage to determine if the care [of a patient] was the right care, at the right time and in the right setting," said Szucs, RN, CCM, case management supervisor at Cigna, a global health service company.
“Case management nurses still have that role to some extent, but today we are moving much more into health advocacy. We play a much larger role in teaching customers about their care, emphasizing prevention and how to avoid illness. We’re using innovative techniques to empower people to take better care of their own health. It’s a fresh approach and one that people value.”
Szucs, who previously worked in critical care, cardiothoracic and rehabilitation nursing, has worked for Cigna for 16 years. As a case manager and a supervisor, Szucs can take a step back and look at things from a different perspective.
“I can ask how we can make changes to make our services better,” she said.
Seeing the big picture
When Farr started her nursing career, she remembers having diagnosis and nursing goals for her patients.
“We were adept at telling them what to do. Our goal was to get them well,” said Farr, RN, CCM, case manager on Cigna’s complex case team.
Today, Farr uses her assessment skills to listen, encourage and help patients get the right treatment, accept difficult diagnoses and find solutions for a better quality of life.
Farr spends her days on the phone performing a multitude of tasks. She helps patients transition from hospital care to home care and explains diagnoses or treatment plans. She also obtains access to doctors, coordinates health benefits and helps patients better manage chronic conditions.
“Maybe it’s my critical care background, but I love coming into mass confusion and bringing order out of chaos,” Farr said.
It’s not unusual for a routine case to become more complicated.
“I had an elderly woman who was sent home from the hospital after a diagnosis of pneumonia,” Farr said. “No home health [care] had been prescribed but in following up with her, I learned she was uncomfortable with her doctor’s diagnosis. She thought something else was wrong.”
Farr encouraged the woman to seek a second opinion and a doctor found permanent lung damage from a 15-year-old chemical injury. Despite oxygen treatment, she ended up back in the hospital and faced a lung biopsy.
“I talked to her frequently. She was extremely ill and scared, but ultimately came to the decision to have the biopsy,” Farr said.
Unfortunately, the patient died soon after.
“Coaching her through that process was very emotional, but I considered it successful, because the last time I talked to her, she was at peace that she had done what she needed to do and was glad that someone had helped her,” she said.
While Farr is not a therapist, she has learned to be an expert listener, thanks to Cigna Care Coaching, a training program the company launched in 2007.
“It’s an intense 15-week course with readings, case studies and role-playing to try out different methods and techniques,” Szucs said. “Our case managers and health coaches go through it to learn better communication skills. They learn how to actively listen for what is said and not said, how to ask reflective, open-ended questions and to use motivational interviewing techniques to help clients make better decisions for their health.”
Farr said the course helps nurses and coaches identify their own belief systems.
“That self-awareness is very important in working with a multicultural population,” she said. “It helps case managers get past the ‘righting reflex’ — of wanting to fix things their way — and allows them to let the customer come to his own conclusions.
“We used to choose the best treatment for patients or list their options. Now I give them resources and encourage them to go on their own fact-finding missions in order to find the solutions that meet their needs. I’ll ask if they’d like more information and wait to be invited into the decision-making process.”
Importance of relationships
Szucs and Farr have learned that listening and offering information — rather than telling patients what to do — is a better way to convince people to change poor lifestyle choices such as smoking, eating fatty foods or not exercising.
“I’ve had people tell me that they weren’t going to do something, then turn around and change their minds because we kept calling and listening. We didn’t give up on them,” Farr said.
According to Szucs, working relationships between case managers and physicians have improved since she started in the field.
“Originally, other providers saw it as interference,” Szucs said. “The role of patient advocate was considered more adversarial, but now physicians and other health care practitioners see our help in a more positive light. After all, we have the same goal — to get patients to the right level of care.”
Farr believes case management will be at the forefront of a changing health care system. When she goes to seminars, she meets case managers who work in various settings, including community health centers, hospitals, doctors’ practices, private companies, clinics, insurance companies and employee health organizations.
“Basically, case managers can be helpful anywhere someone has a need to engage in health care,” she said.
Szucs loves meeting people in what is often the most traumatic period of their lives and offering education, options, answers and resources to help with their problems.
“Fundamentally, we get to help and empower people. I love this job,” she said.
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