C O L L A B O R A T I V E C A S E M A N A G E M E N T
Patient-Centered Case Management In The Acute Care Setting
by David Esquith, MSW
Dr. Naleppa’s case management model (see page 5) presents a system for involving the patient in a process to ensure that tasks are prioritized,
responsible parties are identified, work is completed, and an evaluation is performed. This is a robust model for the delivery of case management
services in the outpatient arena or in a healthcare system that provides case management services to patients across the continuum. This article
will suggest modifications to that model to bring the patient-centered, task-centered model into the acute care setting. These modifications build on
the core principles of Dr. Naleppa’s model but respond to the compressed time periods of acute hospital stays.
In an acute care setting, social workers or case managers (SW/CM) must
develop a practical plan for the patient’s needs at discharge, sometimes as
early as within 24 to 48 hours after admission. Knowledge of the patient’s
discharge plan can impact the treatments and procedures that are
performed while the patient is hospitalized. Therefore, a tentative outline
of the discharge plan early in the hospitalization is a valuable tool for the
entire healthcare team. To identify and develop a plan within the time
constraints prescribed requires the involvement and cooperation of many
individuals. While the patient remains the center of this process, there
are others who are equally important to it. These include his/her family,
the physician(s), other members of the healthcare team (e.g., nurses,
therapists, dietitians, etc.), and, frequently, community resources that
are currently in use by the patient or that may be needed to ensure a safe
return to the community.
COMPLEXITIES OF ACUTE CARE CASES
Patients who are acutely hospitalized often face a myriad of
overwhelming issues. Even in reasonably benign situations or those
that are planned (e.g., obstetrics or elective surgery), patients deal with
heightened anxiety and the worries and fears that can accompany illness or
injury, loss of control, and changes in lifestyle. Frequently, patients in these
circumstances also face financial pressures and separation from other
family members.
An acute hospitalization typically takes a great emotional toll. When
the reason for hospitalization is less benign – such as a newly diagnosed
cancer, a cerebral vascular accident with paresis or the trauma of an
automobile accident – the patient is often emotionally frayed and requires
all of his or her emotional strength to cope with the illness. In these
circumstances, patients are faced with issues and decisions of variable
intensity. These range from “who will care for my pet?” or, “how will I pay
my rent while I am away from work?” to “who will take my children if I die?”
Issues of discharge, and the decisions that are often required, compound
the stress and can impact the patient’s ability to actively participate in
discharge planning. Lack of cooperation in discharge planning may also be
secondary to resistance to leaving the hospital, limited resources impacting
their ability to function in the community (within an environment they
are accepting of), or a variety of cognitive and psychological variables that
limit their abilities.
Often additional barriers complicate the development and
implementation of a viable plan for the patient’s post-acute needs. These
may include family members who are resistant to exploring future plans
or physicians who are not motivated, for a variety of reasons, to facilitate
such planning. SW/CMs routinely face a barrage of obstacles erected by
family members that include anxiety regarding their relatives’ readiness
to be discharged, hesitancy about making plans before the patient is
“cured,” concern about the long-term impact of their involvement,
or simply lack of time. It is also not uncommon to encounter family
members who are simply not interested in taking an active role
in assisting the patient with his or her needs. The counseling and
facilitation required to engage reluctant family can be time-consuming
and stressful.
7
Adding further complexity to the dynamics, there are some common
reasons that physicians on the healthcare team may be unwilling to actively
pursue a timely discharge and aid in the planning process. These include,
but are clearly not limited to:
1 a desire to keep the patient hospitalized because there are rarely
financial incentives to discharge,
2 a desire to avoid emotionally taxing and time consuming discussions
of patient or family objections to discharge, and
3 a preference for coordinating various procedures (whether or not
it is appropriate to do them on an in-patient basis) while a patient
is hospitalized.
There are also physicians who view the discharge planning process
as adversarial to their treatment of the patient. This attitude has a direct
negative correlation to their level of participation in, and support of, a timely
discharge planning process.
AN ACUTE CARE MODEL
Despite these seemingly overwhelming barriers, it is not only feasible
but practical to utilize a patient-centered / task-centered approach to plan
for a patient’s needs after an acute hospitalization. To do so requires an
approach that takes into consideration these unique issues of the acute
care setting.
One primary consideration in developing a modified model is that
there are rarely opportunities for open-ended discussions with patients
and their families. Whether the case being considered is fairly simple and
straightforward or is a more complex, problem-riddled one, the SW/CM
must perform a series of steps both prior to and following a face-to-face
assessment. The initial process will involve a review of the medical record to
obtain a clear understanding of:
1 the patient’s past and present medical history,
2 residual issues that will need to be considered when making
a discharge plan,
3 the approximate length of stay that is to be expected, based on
the current treatment regimen, and
4 information about the patient’s pre-morbid living situation.
Following this, a brief discussion with other members of the healthcare
team must take place to gather more information about the patient. The
consulting and attending physicians can augment the chart information
with specific post-discharge treatment needs that can help guide the post-
acute care planning. Nursing staff can provide valuable information as to
the patient’s functional status, such as activities of daily living, toileting,
ambulation, and his or her willingness and ability to participate in self-care.
All of this information provides a more detailed picture of the patient that
prepares the SW/CM for the most productive interaction with patient and
family under the omnipresent time pressure. Finally, therapists, dietitians,
and others complete the portrait by providing information about the
patient’s current and projected needs. With all of this information assembled,
it becomes possible to formulate a preliminary plan for the patient upon
discharge. (continued on page 8)
 w w w . a c m a w e b . o r g
A Model of Social Work Case Management (continued from page 6)
difficulties with her financial management. Although the client’s son
manages most of her finances, he had no Power of Attorney (PoA). This
prevented him from completing certain financial transactions. The case
manager suggested a task that the daughter would obtain, complete,
and file a PoA form with the town clerk. It was not completed because
the family changed its mind and further discussion led to a decision to
postpone further work
in this area.
TABLE 3:
The client had
indicated problems with PROBLEM CHANGE SCORES
housecleaning. She also
TARGET NEED
expressed the need for
help with some errands. Lack of medical equipment
The problem had come Financial management
up only sporadically,
since the daughters Homemaker service
were usually available Emergency information
for help. However, the
*1-2 = much worse, 3-4 = little worse, 5 = no change, 6-7 = little better, 8-9 = much better, 10 = not present
client did not want to
overburden her support
system and expressed
her preference for more independence. The case manager suggested and
carried out a referral to a home assistance program for a companion to
help the client for 3 hours every other week.
The client had no emergency information that was easily accessible when
needed. The case manager initially identified this problem. The task related
to this area of need was to fill out a Vial-of-Life, place it in the refrigerator,
Matthias Naleppa is an associate professor at Virginia Commonwealth University. He received his MSW at the Catholic School of Social Work,
Munich, Germany, and his Ph.D. at the State University of New York at Albany. Dr. Naleppa’s scholarship includes the areas of practice evaluation,
clinical case management, practice with the elderly, task-centered social work, and international social work.
Patient-Centered Case Management (continued from page 7)
Once a working plan is in place, the SW/CM will have a face-to-face
meeting with the patient. This direct assessment affords the SW/CM
the opportunity to confirm information obtained earlier, ascertain the
patient’s perspective and desires (which may differ considerably from
those of the healthcare team), and begin identifying other cognitive,
behavioral, or emotional factors that may not have been noted. Another
component of the direct assessment is a discussion with family members
who may have an integral role in the patient’s life. The family can provide
the breadth of information that allows fine-tuning of the discharge plan.
The preliminary information then is blended with the results of the direct
intervention to modify, if necessary, the options under consideration.
This process provides the SW/CM with a tentative plan, based on the
synthesis of objective and subjective information about the patient, which
will then be reviewed by the patient. By developing the plan in this way, the
SW/CM is able to explore with the patient, in a reasonably directed manner,
his/her needs and the post-acute, community resources that may be used to
meet them. This step-by-step process is sensitive to the patient’s need to be
involved in the decision-making while also respecting time constraints. The
patient is not overwhelmed by too wide a range of choices, and yet is able to
have significant input to the ultimate plan.
Once this process has produced a “working plan,” the SW/CM
can help guide the patient and family towards implementation. The
patient or family members who are willing and able to participate
and place identification stickers on the refrigerator and outside door.
Unavailable information on blood type was to be added later. The task was
collaboratively completed.
Table 3 shows that three of the target needs were successfully addressed.
The client changed her mind on the importance of financial management
support, terminating the work on the related tasks. Overall, there seemed to
be a correlation between
successful completion of
the tasks and the changes
in problem status.
PROBLEM CHANGE SCORES*
CONCLUSION
8 This article
5 provided an overview
of a practice model
10 that integrates case
10 management functions
with strategies of brief
treatment. Some of the
main features include
a highly structured
client-centered practice approach and the integration of measures of
accountability and effectiveness.
REFERENCES:
Naleppa, M. J. & Reid, W. J. (2003). Gerontological Social Work:
A Task-Centered Approach. New York: Columbia University Press.
are matched with the appropriate tasks in the plan. The SW/CM will
take the lead in this effort and in the process, help the participants
understand and (ideally) accept their roles. Naturally, external
variables such as time constraints play a role in the SW/CM’s efforts
to keep the process on track. In circumstances when the family is
available and willing to participate, much of the responsibility will
shift to them. When this is not the case, the SW/CM must assume
more of the workload. Because of the need to ensure that everything
is completed in a timely manner, the involvement of family has to be
balanced with their ability and willingness to meet the needs.
A patient-centered, task-centered model for the acute setting, with its
inherently tighter timeframe, requires a focused and directed approach by
the SW/CM. By ensuring that the patient, unless incapable, remains the
central focus and that his or her family is involved to the greatest possible
extent, there is a significantly higher likelihood of success. Including the
patient and family in this process creates more connection to the plan, which
in turn is a key predictor of both success and satisfaction.
David Esquith is the Manager of Medical Social Work in the Department of
Case Management at Cedars-Sinai Medical Center in Los Angeles, CA. He holds
Master’s Degrees in Social Work from the University of Southern California
and Public Administration from the California State University Consortium.
He is a California Licensed Clinical Social Worker.