Case Management … Care Coordination … Yeah, Whatever
The basics of care delivery are broken. And must be fixed … now.
By George Martin, MD – Senior Medical Director for Health Integrated
The telephone conversation went something like this:
“Good morning. This is Stan Smith,” I said.
“Hello is this Mr. Smith?,” came the response.
“Yes, this is Dr. Smith. How can I help you?,” I replied
“Mr. Smith, this is Delilah, your wife’s case manager and I need your home address,” said the voice at the far end.
My wife had been in the hospital for the past five days and this was the first that I knew of a case manager. So I relayed our home address to her, even though it was on file in the admission papers. Perhaps the computer was down again. That had been the last excuse as to why my wife’s procedure had been delayed … for the fourth day.
But Delilah said, “No, I need your local address.” Our home is far enough from my work location that we maintain an apartment in the city where I work so as to minimize the commute. Normally I spend four nights at the apartment and my wife joins me for two, but since she has been ill and in need of care, we have been at the apartment five days a week, returning to our house for the weekend. So I related the local address to Delilah.
But then I thought, “Why do you need our local address?” So I asked.
Delilah responded “The doctor has ordered home health care for your wife.”
“What home health care has he ordered?,” I queried.
“He wants blood drawn weekly and the nurse will come out to do the draw,” she said.
“I can take her to the lab for the blood to be drawn. I see no need for home health.” I answer.
Delilah answers, “Don’t worry, it won’t cost anything.”
As you might guess, I am now a little perturbed. Her presumption of cost as the issue was not remotely my point, but I play devil’s advocate and ask, “Oh, are they doing this for free?”
Again Delilah answers, “No, but your insurance will cover it.”
My response was, “I still don’t think it’s necessary.”
“So you wish to decline home health care? You can decline if you wish,” she stated.
“Yes. We wish to decline home health care.” I confirm.
“You’re sure?,” she asked again.
“Yes! I will take her to the lab for the blood draws,” I insisted. And I thought that the decision was made.
“Delilah, then is my wife to be discharged today?” I asked.
“I don’t know,” Delilah responded.
This occurred at 9:30 AM on Tuesday past. My wife’s admission the previous Thursday had gone reasonably well. Within three hours of arrival through the emergency department she had been admitted, arrived on the patient care unit and had the required procedure scheduled for the next day. IV and medication had been given. The procedure was promised for the following afternoon with the anticipation that it might get done in the morning. So much for plans and managing patient and family expectations.
Three and one-half days of sitting with my wife awaiting a necessary procedure was tough on me. Imagine how difficult it was for her. She was ill and the nursing staff wondered why she was cranky after three nights of being awakened for vital signs while wearing a set of telemetry leads attached to a three-quarter pound box that pulls at your skin every time you try to roll into a comfortable position on a cold hard hospital bed. Surprisingly, they did not connect the lack of information as to the actual timing of her procedure and her ultimate discharge as significant contributing factors to her irritable demeanor.
Care management, care facilitation, care coordination, call it what you will, should be much easier in the inpatient environment, if for no other reason than that both the patient and the provider(s) are physically present. The required care is generally defined and the effort should be to see that necessary care is delivered efficiently. When care is reimbursed on a case rate (DRG) basis, the facility also accepts the financial risk for delays in care and poor care coordination.
Though I have long believed our healthcare system is broken when considering our lack of care coordination, but walking a mile in patients’ shoes brings a whole new level of appreciation for their frustration with the system.
And your thoughts and experiences? Let me know! Thanks in advance for your input. You can reach me directly at healthexecforum@healthintegrated.com, or comment directly in the blog.
George Martin, MD
P.S. My wife did go home and is doing better but still has a long road to recovery.
Perhaps, we should add EFFECTIVE Care Coordination to the litany of names that we use now. Case Managers might learn to ask questions about what the patients need and seek to fill those needs rather than fill the anticipated need with a one size fits all approach….
What i find most distressing about this conversation with the case manager is the lack of information – what tests, how often, who is ordering, and why, for goodness sake, if they know the spouse is in the medical field, they don’t VOLUNTEER this information.
We use something we call motivational interviewing – we ask questions!!!!!
“Your wife’s physician thinks home health would be appropriate for xxxx reason, to provide xxx service. We talked to your wife about it. Would you like to speak to her and then TALK to us about the plan????? We could have the case manager available to answer any questions you might have about this. BUT NO, just cram their agenda down your throat. Shame on them. Ellen Smith RN. 35 years in this business, and it’s worse every day.
On behalf of George Martin, MD
So true, Kerry, so true! Thanks for your comment.
On behalf of George Martin, MD
My issue is that they are still in the midst of what I call the “surprise discharge”. Not only was there no case management but discharge planning did not begin until the physician wrote an order.
After many years as a nurse, I found that the Medical Professional might be more successful by finding the need or desired outcome of the patient and family first. Only then can the clinician begin to educate and integrate the tasks for managed care. The art of healing comes from many years of experience. I sometimes fear the future since we have placed our efforts in dashboards, grafts and data spread sheets. Old ways are gone but please remember that some ways of the past are worth their weight in gold. Outcomes will be better.
On behalf of George Martin, MD
Truer words were never spoken, Joanna. Sometimes in our haste to improve “efficiency”, we get lost in the process and lose sight of the people involved. Healthcare is one area where people MUST BE considered wholly in the process.
I have seen HI SNP Care Models and they are impressive. Seems like a service to providers that would help everyone.WPB,Fl