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Faculty case management: An innovative approach in a primary health care clinic
MANAGEMENT STRATEGY by Donna Wilsker, MSN, RN, Kathy Roberts, MSN, RN, M. Fran Skeels, PhD, APRN, BC, and Cindy Stinson, MSN, RNBC
U
bi Caritas (“Where Mercy Dwells”) Health Clinic emerged as the realization of a partnership among the Lamar University Department of Nursing (DON), the Ubi Caritas executive board (appoint-
ed by the Episcopal Diocese), and several communities in south Beaumont, Texas. These groups responded to the need to improve access to health services for the medically underserved population around them. This population historically used emergency department (ED) services rather than primary health care providers, draining the county’s allocated health care budget. The needs assessment process that preceded the clinic clearly demonstrated that the people who resided in south Beaumont perceived more problems in their lives than other local individuals. In addition, community gatekeepers, city officials, political leaders, and serTCM 62
September/October 2002
vice agency representatives were interviewed and concurred that the targeted population had an inordinate number of health-related issues. We pursued several sources of funding for the clinic. The Episcopal Diocese
pledged $500,000 for the first year of clinic operation to renovate the building, maintain operations, and support staff salaries. The DON won a 3-year Department of Health and Human Services (DHHS) grant for $920,000 to establish a nurse-managed, communi-
VIGNETTE 1: INTERVENTION FOR ACUTE NEED One of the clinic’s first clients, GM, a 57-year-old white man who lived alone in a tiny rental home, drove a battered vehicle, and had no access to any communication devices, presented to the nurse practitioner with acute retinal bleeding. We were able to have GM seen the very next day at the hospital’s ophthalmology clinic. Immediate surgery was scheduled, and GM’s vision was saved. When GM returned to the clinic, his next urgent problem was extensive dental work. He was frail because eating had been difficult for a prolonged period. Dental assistance for low-income clients had been and continues to be a significant concern for local health care providers. Because GM had at least a small amount of income, the case managers were able to arrange an appointment at the nearest university dental school, approximately 100 miles away. After 8 months of appointments, extractions, impressions, and fittings, GM finally had dentures that allowed him to eat. Now we see a smile on his face and a healthy weight gain of several pounds. We still see GM fairly regularly in the clinic as one of our chronic asthma clients. He is able to afford his medications through our PAP, which saves him a significant amount of money and allows him to comply with his medication regimen. When GM does not have a regular appointment, he still visits the clinic to provide progress reports to the case managers and other staff. As Jacobson et al.4 reported, “Case managers experience great personal satisfaction from their work and are readily able to see that their efforts have made important differences in clients’ lives.”
ty-accessible clinic for a medically underserved population. The original grant included funding for a nurse manager, a nurse practitioner, and 4 part-time case managers at the clinic. In addition, the DHHS grant enabled faculty case managers to establish a referral network for care, outreach services monitored by a community health care worker, and clinical experiences for both undergraduate and graduate students.
FIGURE 1. CASE MANAGER MONTHLY SUMMARY REPORT
We recognized early on that we needed additional case management (CM) support during our first year to develop partnerships and clinical tools. We submitted a second grant proposal to the Helene Fuld Trust Fund to support faculty involvement in active clinical practice through CM and develop the case managers’ cultural competence. Evolution of the CM Role The grant proposal mandated the use of CM to provide a seamless system of primary health care services for medically underserved adult and child populaSeptember/October 2002
TCM 63
VIGNETTE 2: INTERVENTION FOR AN INFANT WITH SPECIAL NEEDS As the petite Mexican woman entered the clinic clutching a small bundle, the staff wondered about the baby it contained. As she shifted her load, we glimpsed an infant about 4 months old. Her face was normal, but as our gaze traveled upward, we noticed the bilaterally depressed frontal bones. A further quick assessment revealed that the child did not move and seemed to be unaware of her surroundings. The mother spoke almost no English and demonstrated no comprehension. Our Spanish-speaking assistant encountered trouble translating because of a difference in dialect and the mother’s reluctance or inability to convey needed information. The scanty information obtained from the mother revealed that the baby girl had been born in Mexico and had a shunt placed in her head immediately after birth. Mother seemed unable to give any reason or much of a history. She had brought her to the clinic because of constant seizures. Physical examination revealed a smaller-thanaverage female who experienced constant tremors. She did not respond to verbal or visual stimuli and lacked any of the expected motor skills of a child her age. The nurse practitioner and case manager realized that this child and her mother needed all community resources available to them. Both were Mexican citizens and thus not eligible for Medicaid. Basic laboratory tests were obtained through the clinic. The child needed immunizations, but the mother did not know which ones. In addition, based on her uncertain neurologic condition, she was not a candidate for some of the recommended immunizations. Many factors limited the clinic’s ability to provide appropriate nursing care for this infant. A collaborative telemedicine clinic existed between the DON and the DRF that allowed medically fragile children to be seen locally by a team of physicians and ancillary health care providers from the DRF. After missing several appointments, the mother brought the baby to the telemedicine clinic. The DRF physician immediately arranged for her to be evaluated thoroughly at the DRF location. Public transportation was available, but the family could not afford the $88 per-person round-trip cost. UBI Caritas Clinic paid for the trip, the infant was evaluated, and appropriate health care was initiated. The family was told about resources available to them while they were in Texas. The ongoing collaboration between the clinic and the DRF allowed this infant to receive appropriate health care.
tions in the South Park and West Oakland/Pear Orchard areas of Beaumont. Our intent was to use advanced practice nurses who concurrently served as faculty members at Lamar University in the same city. In the first year of the grant, 6 nursing faculty members served as case managers when additional funding sources were available. The luxury of the added case managers allowed time for role development and community networking. In the second and third years of the grant, 4 faculty members worked 1 day a week as case managers. Each faculty member worked 8 hours a week at the clinic and answered after-hours calls on TCM 64
September/October 2002
a rotating basis by using approved triage protocols. Each case manager had a different area of expertise, including community, maternal/child health, psychiatric, and medical/surgical nursing. During the 3 years of the grant, the case managers learned, through trial and error, the true meaning of teamwork and communication, ultimately delivering quality affordable care to a medically underserved community.
program to help them. Additionally, the case managers attended several seminars designed to enhance CM skills. We soon realized a plethora of CM definitions and models existed,1 and we needed to develop our own definition and functional CM model based on our unique clinical situation.2 Finally, we visited ambulatory nurse-managed clinics in state and out of state to gather as much working knowledge as possible.
Initially, no framework was available to provide a model for this unique CM role. The case managers met and reviewed the literature extensively to compile a job description and clinical pathways and to develop a computer
The goals of the CM role were two-fold: to gain early access for this population into the health care system through a referral system and to prevent complications through education and follow-up care. Case managers worked closely
VIGNETTE 3: INTERVENTION FOR THE OBESE CLIENT AT is a 64-year-old white woman. She arrived at the clinic in June, asking for a “physical.” She recently had become a widow after 48 years of marriage. Her mother also died during the previous year. This client was the mother of 8 adult children, 2 of whom still resided at her house. AT was 5’4” and weighed 272 pounds. On her initial visit, her blood pressure was 150/100 and total cholesterol was 260. She gave a history of “being out of breath, out of shape, and having a flair-up of her arthritis.” She was placed on blood pressure and cholesterol medications and was referred to the case manager for weight management. At the first session with the case manager, AT completed readiness, risk, and activity questionnaires. She also was asked to maintain a food diary for 1 week. The next week, the client and case manager worked together to devise an individualized weight program based on the previous assessment and food diary. The program included a walking schedule and workable meal plan. The meal plan considered her food preferences, budget, lifestyle, and family obligations. By the end of July, the client had lost 5 pounds and was attending a motivation class at her neighborhood church. Within 2 weeks, her children had pooled their money and bought her a stationary bike. By September, the client had lost 10 pounds. She continued to meet with the case manager for 30 minutes every 2 weeks. Reassessment and changes in the weight management program were made at these sessions. Discussions centered on obstacles, achievements, and creative approaches to weight management. On the first Friday of each month, she also attended educational group meetings covering a variety of subjects with outside speakers. Topics included subjects such as stress reduction and how to cook low-fat meals. Meal plans were tailored for vacations and to allow the clients the flexibility of eating out. When an adult son moved out and the client was upset, she met with the psychiatric case manager to discuss stress management. One year after initial contact, the client had lost 20 pounds and was wearing dresses two sizes smaller. In addition, her total cholesterol had decreased to 240. Vital signs at this time measured her blood pressure at 136/80 and pulse at 84. She continued to take her blood pressure and cholesterol medications, but said she no longer had problems with her arthritis and had more energy with less shortness of breath. Positive outcomes were evidenced by the objective data of decreased weight and laboratory values and subjective data of reported health benefits. The case manager and the client continued to meet at scheduled meetings. As More and Mandell5 noted, “In today’s health care environment, with its emphasis on prevention and critical pathways, the need to identify potential problems becomes an integral part of the process.”
with other members of the health care team to provide education and referrals for a variety of clients with differing health care needs, such as cancer, diabetes, asthma, and hypertension. As each case manager became more familiar with her role, programs evolved, such as a weight management program with individual appointments, referral services for free eye examinations for diabetic clients, and referrals for free mammograms for women. An advanced clinical nurse specialist in psychiatric nursing provided appointments for depression, anxiety, and panic disorders. A 1997 article3 said, “In most CM programs, there is no technique or mecha-
nism to collect data on interventions used by case managers in an ongoing, prospective manner.” At Ubi Caritas, the case managers took advantage of available technology to enhance communication and track the types of services provided to clients. For example, the case managers used the “Tasks” component of Microsoft Outlook to organize, plan, and communicate daily needs of clients. In addition, a spreadsheet tool (Fig 1) was developed to quantify case manager services. Early in role establishment, we developed clinical outcomes to monitor progress of care. Figure 2 is an example of a clinical outcomes checklist for obe-
sity. This documentation provided numbers to identify the major functions performed and areas of major concentration for this role. A community worker worked closely with the case managers to provide home visits, transportation, food, and prescription assistance program enrollment. As documented by clients and clinic staff, this model enabled clients to receive cost-effective, quality care in a safe environment. Evolution: Faculty Practice The DON’s grant proposal to DHHS indicated that the clinic’s CM services would be contracted with advanced practice nurses from the DON Faculty September/October 2002
TCM 65
FIGURE 2. OUTCOME CHECKSHEET FOR OBESITY
Practice Program. The DON had implemented this plan during the 1996 academic year. Two specific goals of the program involved participation at Ubi Caritas: promoting community links to help diverse health care consumers receive quality care in a changing environment and supporting nursing faculty to meet the challenges of a redefined TCM 66
September/October 2002
educational system by promoting faculty practice. The DON adopted an entrepreneurial model that allowed the faculty to negotiate with a community agency to provide services 1 day a week for which the department is reimbursed. Revenues are shared between the DON and the prac-
ticing faculty member, who is expected to maintain his or her usual workload and responsibilities. Faculty also are expected to use the Faculty Practice Program to increase community links, maintain clinical expertise, provide opportunities for student clinical experiences, and expand clinical research opportunities.
VIGNETTE 4: INTERVENTION FOR THE CLIENT WITH MENTAL HEALTH PROBLEMS We met LS the first summer we were case managers at Ubi Caritas. Her presenting need was for a referral for a gynecologic problem, but it was quickly evident she had additional needs. She did not have the $60 needed for the DRF visit, let alone the added 50% of any laboratory or radiology charges, and reliable transportation for the 2-hour drive was not available. LS’s emotional state was in a turmoil, even suicidal, so we made referrals to the rape and suicide crisis hotline and family services. LS was living on approximately $600 per month and had no money for counseling. Fortunately, visits with the mental health clinical nurse specialist (CNS) at Ubi Caritas were free. In the role as a case manager, the CNS assisted in referring clients to local mental health agencies for care but also made appointments for clients who were referred by the family nurse practitioner. LS was followed intermittently by the CNS as needs were expressed. During the 2 years of our contact, LS struggled with relationships with her two grown daughters, ex-husband, mother, and others. She was a graduate art student at the local university and taught private art lessons for income. Grants and loans paid for her schooling, and very little was left for health care. During the first therapy session, the immediate and primary problem identified was difficulty with stress management. She was shown how to perform a self-assessment and was given other material on assertiveness. Many years of living with her abusive ex-husband had not helped her coping skills. Her actions were analyzed and constructive coping methods were identified, but it was difficult for her not to return to the old, aggressive ways of relating to family. Her anxiety decreased after using a relaxation and imagery tape made by the CNS. Eye contact improved. The family nurse practitioner at the clinic prescribed an antidepressant, but LS did not like the way it made her feel, so she discontinued it and returned to an herbal stress compound from a local health food store. The compound seemed to help when she had the money to buy it. Soon after LS began meeting with the CNS, her ex-husband had a heart attack and died, complicating the family situation even more. Obsessive-compulsive behaviors surfaced, so she and the CNS developed techniques to deal with this problem. The CNS learned LS’s mother also had obsessive-compulsive disorder. LS said her ex-husband had been diagnosed with borderline personality disorder, and she feared her youngest daughter could develop this problem. Many financial, physical, family, and emotional problems continued. LS had no supportive friends or relatives. She developed severe back pain that led to sleep disruption and bruxism. The FNP prescribed BuSpar, but LS was uncomfortable with the side effects, and a reduced dosage did not help. Rational emotive therapy (RET) techniques were introduced to deal with LS’s irrational thinking patterns. She began to make progress by using the RET approach to cope with stresses and problems. LS took another job and met a new male friend, who progressively became a special part of her life. At last she had a friend with whom to share her concerns. Her appearance became more energized and attractive. Her relationships with her daughters improved. LS’s emotional status and coping continue to be more stable after 2 years of intermittent therapy. She has not finished her college degree, but the friendship with her male friend has survived—truly an accomplishment for both of them because they had problems finding compatible, lasting relationships. LS has received a promotion and hopes to continue employment at a museum. Her health problems are much less frequent now after therapy and having a real friend with whom to share life. Powell2 said, “More important than the definition of CM or what nurse managers accomplish is the heart of their role: the holistic and humane care of both the patient and their family.”
Evolution: Community Resources Identifying resources for clients is often a challenge, much like solving a mystery. The case managers are expected to develop a list of resources for clients. Some basic resources were identified initially, but many more have been cultivated as time progresses and client needs are determined.
Jefferson County has no county hospital, and one of the more pressing needs before the clinic was a referral source for diagnostic, surgical, and specialty services. The designated regional indigent care facility (DRF) is approximately 2 hours away, an impossible trip for many of our clients. For others, the trip was possible but inconvenient, requiring
missing a day’s work or paying someone to take them. People with older, unreliable vehicles also faced a problem. Finally, if clients did not follow county financial screening protocols before they journeyed for their appointments, the cost for the visits or tests could be as high as with a local specialist. SomeSeptember/October 2002
TCM 67
times clients merely refused to go or just never complied with the process, even if they did not verbally refuse. Even if clients kept their appointments, the cost could be prohibitive. Diagnostic cardiac tests that regularly cost $800 were only $200 at the reduced rate for Jefferson County residents, but that figure was still exorbitant for our clients! Occasionally, clinic clients were eligible for referral to the family practice clinic at the local religious hospital, where they would receive diagnostic tests and care for a minimal cost. If they qualified, hospitalization was free. Initially, limited medication samples were available from pharmaceutical representatives for needy clients. If samples were not available, clients could not get the medication unless they were eligible for limited local assistance. Case managers learned about the prescription assistance programs (PAPs) available for many medications from pharmaceutical companies for those who cannot afford to purchase routine medications and who are not on insurance or Medicaid plans. PAPs gave drugs for free or a nominal fee if clients qualified financially. However, maintaining the program was almost a full-time job for one employee because the paperwork, telephone calls, and tracking were very involved. An outstanding local resource for women was the Julie Rogers Gift of Life Free Mammogram program. Women older than 50 with low incomes or a history of special circumstances were eligi-
ble. At first, case managers had to refer the women to the local Gift of Life office, which determined eligibility and referred clients to a local hospital for screening. Soon, the case managers received permission to do the eligibility screening and refer clients directly for the free mammogram. The case managers continue to work with this foundation to provide follow-up care. Conclusion The CM process helps many culturally diverse clients with a variety of physiologic, psychosocial, and emotional needs. The sidebars highlight some of the complex needs addressed in our roles as case managers. During the 3-year grant period, the case managers watched a working definition and model of CM evolve. As demonstrated in the vignettes, we did not always have all the answers, but we were adaptable and persistent in our efforts to provide quality client care—a true indication of client advocacy. Quality CM also manifests in care coordination, teaching and learning outcomes, counseling successes, and seamless health care delivery. Based on clients’ written and verbal responses, our activities were appreciated.
2. Powell S. Nursing case management: a practical guide to success in managed care. New York: Lippincott; 1996. p. 5, 6, 25. 3. Issel L. Measuring comprehensive case management interventions development of a tool. Nursing Case Management 1997;2(4):132-8. 4. Jacobson S, MacRobert M, Leon C, McKennan E. A faculty case management practice: integrating teaching, service, and research. Nursing Healthcare Perspectives 1998;19:220-3. 5. More F, Mandell S. Nursing case management: an evolving practice. New York: McGraw Hill; 1997. p. 68. Donna Wilsker, MSN, RN, Kathy Roberts, MSN, RN, M. Fran Skeels, PhD, APRN, BC, and Cindy Stinson, MSN, RNBC, are all assistant professors at Lamar University in Beaumont, Texas. All authors served for 3 years as case managers at Ubi Caritas Clinic. Fran Skeels continues to provide mental health services to clients at the clinic. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/127985 doi:10.1067/mcm.2002.127985
References 1. Howe R, editor. Fundamentals of ambulatory case management. Gaithersburg: Aspen Publishers; 1998. p. 1-12.
BACK ISSUES AVAILABLE As a service to our subscribers, copies of The Case Manager for the preceding 5 years are maintained and available for purchase from Mosby until our inventory is depleted. Please write to Mosby, Subscription Customer Service, 6277 Sea Harbor Dr., Orlando, FL 32887, or call (800) 654-2452 for availability and prices of back issues. TCM 68
September/October 2002
U
bi Caritas (“Where Mercy Dwells”) Health Clinic emerged as the realization of a partnership among the Lamar University Department of Nursing (DON), the Ubi Caritas executive board (appoint-
ed by the Episcopal Diocese), and several communities in south Beaumont, Texas. These groups responded to the need to improve access to health services for the medically underserved population around them. This population historically used emergency department (ED) services rather than primary health care providers, draining the county’s allocated health care budget. The needs assessment process that preceded the clinic clearly demonstrated that the people who resided in south Beaumont perceived more problems in their lives than other local individuals. In addition, community gatekeepers, city officials, political leaders, and serTCM 62
September/October 2002
vice agency representatives were interviewed and concurred that the targeted population had an inordinate number of health-related issues. We pursued several sources of funding for the clinic. The Episcopal Diocese
pledged $500,000 for the first year of clinic operation to renovate the building, maintain operations, and support staff salaries. The DON won a 3-year Department of Health and Human Services (DHHS) grant for $920,000 to establish a nurse-managed, communi-
VIGNETTE 1: INTERVENTION FOR ACUTE NEED One of the clinic’s first clients, GM, a 57-year-old white man who lived alone in a tiny rental home, drove a battered vehicle, and had no access to any communication devices, presented to the nurse practitioner with acute retinal bleeding. We were able to have GM seen the very next day at the hospital’s ophthalmology clinic. Immediate surgery was scheduled, and GM’s vision was saved. When GM returned to the clinic, his next urgent problem was extensive dental work. He was frail because eating had been difficult for a prolonged period. Dental assistance for low-income clients had been and continues to be a significant concern for local health care providers. Because GM had at least a small amount of income, the case managers were able to arrange an appointment at the nearest university dental school, approximately 100 miles away. After 8 months of appointments, extractions, impressions, and fittings, GM finally had dentures that allowed him to eat. Now we see a smile on his face and a healthy weight gain of several pounds. We still see GM fairly regularly in the clinic as one of our chronic asthma clients. He is able to afford his medications through our PAP, which saves him a significant amount of money and allows him to comply with his medication regimen. When GM does not have a regular appointment, he still visits the clinic to provide progress reports to the case managers and other staff. As Jacobson et al.4 reported, “Case managers experience great personal satisfaction from their work and are readily able to see that their efforts have made important differences in clients’ lives.”
ty-accessible clinic for a medically underserved population. The original grant included funding for a nurse manager, a nurse practitioner, and 4 part-time case managers at the clinic. In addition, the DHHS grant enabled faculty case managers to establish a referral network for care, outreach services monitored by a community health care worker, and clinical experiences for both undergraduate and graduate students.
FIGURE 1. CASE MANAGER MONTHLY SUMMARY REPORT
We recognized early on that we needed additional case management (CM) support during our first year to develop partnerships and clinical tools. We submitted a second grant proposal to the Helene Fuld Trust Fund to support faculty involvement in active clinical practice through CM and develop the case managers’ cultural competence. Evolution of the CM Role The grant proposal mandated the use of CM to provide a seamless system of primary health care services for medically underserved adult and child populaSeptember/October 2002
TCM 63
VIGNETTE 2: INTERVENTION FOR AN INFANT WITH SPECIAL NEEDS As the petite Mexican woman entered the clinic clutching a small bundle, the staff wondered about the baby it contained. As she shifted her load, we glimpsed an infant about 4 months old. Her face was normal, but as our gaze traveled upward, we noticed the bilaterally depressed frontal bones. A further quick assessment revealed that the child did not move and seemed to be unaware of her surroundings. The mother spoke almost no English and demonstrated no comprehension. Our Spanish-speaking assistant encountered trouble translating because of a difference in dialect and the mother’s reluctance or inability to convey needed information. The scanty information obtained from the mother revealed that the baby girl had been born in Mexico and had a shunt placed in her head immediately after birth. Mother seemed unable to give any reason or much of a history. She had brought her to the clinic because of constant seizures. Physical examination revealed a smaller-thanaverage female who experienced constant tremors. She did not respond to verbal or visual stimuli and lacked any of the expected motor skills of a child her age. The nurse practitioner and case manager realized that this child and her mother needed all community resources available to them. Both were Mexican citizens and thus not eligible for Medicaid. Basic laboratory tests were obtained through the clinic. The child needed immunizations, but the mother did not know which ones. In addition, based on her uncertain neurologic condition, she was not a candidate for some of the recommended immunizations. Many factors limited the clinic’s ability to provide appropriate nursing care for this infant. A collaborative telemedicine clinic existed between the DON and the DRF that allowed medically fragile children to be seen locally by a team of physicians and ancillary health care providers from the DRF. After missing several appointments, the mother brought the baby to the telemedicine clinic. The DRF physician immediately arranged for her to be evaluated thoroughly at the DRF location. Public transportation was available, but the family could not afford the $88 per-person round-trip cost. UBI Caritas Clinic paid for the trip, the infant was evaluated, and appropriate health care was initiated. The family was told about resources available to them while they were in Texas. The ongoing collaboration between the clinic and the DRF allowed this infant to receive appropriate health care.
tions in the South Park and West Oakland/Pear Orchard areas of Beaumont. Our intent was to use advanced practice nurses who concurrently served as faculty members at Lamar University in the same city. In the first year of the grant, 6 nursing faculty members served as case managers when additional funding sources were available. The luxury of the added case managers allowed time for role development and community networking. In the second and third years of the grant, 4 faculty members worked 1 day a week as case managers. Each faculty member worked 8 hours a week at the clinic and answered after-hours calls on TCM 64
September/October 2002
a rotating basis by using approved triage protocols. Each case manager had a different area of expertise, including community, maternal/child health, psychiatric, and medical/surgical nursing. During the 3 years of the grant, the case managers learned, through trial and error, the true meaning of teamwork and communication, ultimately delivering quality affordable care to a medically underserved community.
program to help them. Additionally, the case managers attended several seminars designed to enhance CM skills. We soon realized a plethora of CM definitions and models existed,1 and we needed to develop our own definition and functional CM model based on our unique clinical situation.2 Finally, we visited ambulatory nurse-managed clinics in state and out of state to gather as much working knowledge as possible.
Initially, no framework was available to provide a model for this unique CM role. The case managers met and reviewed the literature extensively to compile a job description and clinical pathways and to develop a computer
The goals of the CM role were two-fold: to gain early access for this population into the health care system through a referral system and to prevent complications through education and follow-up care. Case managers worked closely
VIGNETTE 3: INTERVENTION FOR THE OBESE CLIENT AT is a 64-year-old white woman. She arrived at the clinic in June, asking for a “physical.” She recently had become a widow after 48 years of marriage. Her mother also died during the previous year. This client was the mother of 8 adult children, 2 of whom still resided at her house. AT was 5’4” and weighed 272 pounds. On her initial visit, her blood pressure was 150/100 and total cholesterol was 260. She gave a history of “being out of breath, out of shape, and having a flair-up of her arthritis.” She was placed on blood pressure and cholesterol medications and was referred to the case manager for weight management. At the first session with the case manager, AT completed readiness, risk, and activity questionnaires. She also was asked to maintain a food diary for 1 week. The next week, the client and case manager worked together to devise an individualized weight program based on the previous assessment and food diary. The program included a walking schedule and workable meal plan. The meal plan considered her food preferences, budget, lifestyle, and family obligations. By the end of July, the client had lost 5 pounds and was attending a motivation class at her neighborhood church. Within 2 weeks, her children had pooled their money and bought her a stationary bike. By September, the client had lost 10 pounds. She continued to meet with the case manager for 30 minutes every 2 weeks. Reassessment and changes in the weight management program were made at these sessions. Discussions centered on obstacles, achievements, and creative approaches to weight management. On the first Friday of each month, she also attended educational group meetings covering a variety of subjects with outside speakers. Topics included subjects such as stress reduction and how to cook low-fat meals. Meal plans were tailored for vacations and to allow the clients the flexibility of eating out. When an adult son moved out and the client was upset, she met with the psychiatric case manager to discuss stress management. One year after initial contact, the client had lost 20 pounds and was wearing dresses two sizes smaller. In addition, her total cholesterol had decreased to 240. Vital signs at this time measured her blood pressure at 136/80 and pulse at 84. She continued to take her blood pressure and cholesterol medications, but said she no longer had problems with her arthritis and had more energy with less shortness of breath. Positive outcomes were evidenced by the objective data of decreased weight and laboratory values and subjective data of reported health benefits. The case manager and the client continued to meet at scheduled meetings. As More and Mandell5 noted, “In today’s health care environment, with its emphasis on prevention and critical pathways, the need to identify potential problems becomes an integral part of the process.”
with other members of the health care team to provide education and referrals for a variety of clients with differing health care needs, such as cancer, diabetes, asthma, and hypertension. As each case manager became more familiar with her role, programs evolved, such as a weight management program with individual appointments, referral services for free eye examinations for diabetic clients, and referrals for free mammograms for women. An advanced clinical nurse specialist in psychiatric nursing provided appointments for depression, anxiety, and panic disorders. A 1997 article3 said, “In most CM programs, there is no technique or mecha-
nism to collect data on interventions used by case managers in an ongoing, prospective manner.” At Ubi Caritas, the case managers took advantage of available technology to enhance communication and track the types of services provided to clients. For example, the case managers used the “Tasks” component of Microsoft Outlook to organize, plan, and communicate daily needs of clients. In addition, a spreadsheet tool (Fig 1) was developed to quantify case manager services. Early in role establishment, we developed clinical outcomes to monitor progress of care. Figure 2 is an example of a clinical outcomes checklist for obe-
sity. This documentation provided numbers to identify the major functions performed and areas of major concentration for this role. A community worker worked closely with the case managers to provide home visits, transportation, food, and prescription assistance program enrollment. As documented by clients and clinic staff, this model enabled clients to receive cost-effective, quality care in a safe environment. Evolution: Faculty Practice The DON’s grant proposal to DHHS indicated that the clinic’s CM services would be contracted with advanced practice nurses from the DON Faculty September/October 2002
TCM 65
FIGURE 2. OUTCOME CHECKSHEET FOR OBESITY
Practice Program. The DON had implemented this plan during the 1996 academic year. Two specific goals of the program involved participation at Ubi Caritas: promoting community links to help diverse health care consumers receive quality care in a changing environment and supporting nursing faculty to meet the challenges of a redefined TCM 66
September/October 2002
educational system by promoting faculty practice. The DON adopted an entrepreneurial model that allowed the faculty to negotiate with a community agency to provide services 1 day a week for which the department is reimbursed. Revenues are shared between the DON and the prac-
ticing faculty member, who is expected to maintain his or her usual workload and responsibilities. Faculty also are expected to use the Faculty Practice Program to increase community links, maintain clinical expertise, provide opportunities for student clinical experiences, and expand clinical research opportunities.
VIGNETTE 4: INTERVENTION FOR THE CLIENT WITH MENTAL HEALTH PROBLEMS We met LS the first summer we were case managers at Ubi Caritas. Her presenting need was for a referral for a gynecologic problem, but it was quickly evident she had additional needs. She did not have the $60 needed for the DRF visit, let alone the added 50% of any laboratory or radiology charges, and reliable transportation for the 2-hour drive was not available. LS’s emotional state was in a turmoil, even suicidal, so we made referrals to the rape and suicide crisis hotline and family services. LS was living on approximately $600 per month and had no money for counseling. Fortunately, visits with the mental health clinical nurse specialist (CNS) at Ubi Caritas were free. In the role as a case manager, the CNS assisted in referring clients to local mental health agencies for care but also made appointments for clients who were referred by the family nurse practitioner. LS was followed intermittently by the CNS as needs were expressed. During the 2 years of our contact, LS struggled with relationships with her two grown daughters, ex-husband, mother, and others. She was a graduate art student at the local university and taught private art lessons for income. Grants and loans paid for her schooling, and very little was left for health care. During the first therapy session, the immediate and primary problem identified was difficulty with stress management. She was shown how to perform a self-assessment and was given other material on assertiveness. Many years of living with her abusive ex-husband had not helped her coping skills. Her actions were analyzed and constructive coping methods were identified, but it was difficult for her not to return to the old, aggressive ways of relating to family. Her anxiety decreased after using a relaxation and imagery tape made by the CNS. Eye contact improved. The family nurse practitioner at the clinic prescribed an antidepressant, but LS did not like the way it made her feel, so she discontinued it and returned to an herbal stress compound from a local health food store. The compound seemed to help when she had the money to buy it. Soon after LS began meeting with the CNS, her ex-husband had a heart attack and died, complicating the family situation even more. Obsessive-compulsive behaviors surfaced, so she and the CNS developed techniques to deal with this problem. The CNS learned LS’s mother also had obsessive-compulsive disorder. LS said her ex-husband had been diagnosed with borderline personality disorder, and she feared her youngest daughter could develop this problem. Many financial, physical, family, and emotional problems continued. LS had no supportive friends or relatives. She developed severe back pain that led to sleep disruption and bruxism. The FNP prescribed BuSpar, but LS was uncomfortable with the side effects, and a reduced dosage did not help. Rational emotive therapy (RET) techniques were introduced to deal with LS’s irrational thinking patterns. She began to make progress by using the RET approach to cope with stresses and problems. LS took another job and met a new male friend, who progressively became a special part of her life. At last she had a friend with whom to share her concerns. Her appearance became more energized and attractive. Her relationships with her daughters improved. LS’s emotional status and coping continue to be more stable after 2 years of intermittent therapy. She has not finished her college degree, but the friendship with her male friend has survived—truly an accomplishment for both of them because they had problems finding compatible, lasting relationships. LS has received a promotion and hopes to continue employment at a museum. Her health problems are much less frequent now after therapy and having a real friend with whom to share life. Powell2 said, “More important than the definition of CM or what nurse managers accomplish is the heart of their role: the holistic and humane care of both the patient and their family.”
Evolution: Community Resources Identifying resources for clients is often a challenge, much like solving a mystery. The case managers are expected to develop a list of resources for clients. Some basic resources were identified initially, but many more have been cultivated as time progresses and client needs are determined.
Jefferson County has no county hospital, and one of the more pressing needs before the clinic was a referral source for diagnostic, surgical, and specialty services. The designated regional indigent care facility (DRF) is approximately 2 hours away, an impossible trip for many of our clients. For others, the trip was possible but inconvenient, requiring
missing a day’s work or paying someone to take them. People with older, unreliable vehicles also faced a problem. Finally, if clients did not follow county financial screening protocols before they journeyed for their appointments, the cost for the visits or tests could be as high as with a local specialist. SomeSeptember/October 2002
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times clients merely refused to go or just never complied with the process, even if they did not verbally refuse. Even if clients kept their appointments, the cost could be prohibitive. Diagnostic cardiac tests that regularly cost $800 were only $200 at the reduced rate for Jefferson County residents, but that figure was still exorbitant for our clients! Occasionally, clinic clients were eligible for referral to the family practice clinic at the local religious hospital, where they would receive diagnostic tests and care for a minimal cost. If they qualified, hospitalization was free. Initially, limited medication samples were available from pharmaceutical representatives for needy clients. If samples were not available, clients could not get the medication unless they were eligible for limited local assistance. Case managers learned about the prescription assistance programs (PAPs) available for many medications from pharmaceutical companies for those who cannot afford to purchase routine medications and who are not on insurance or Medicaid plans. PAPs gave drugs for free or a nominal fee if clients qualified financially. However, maintaining the program was almost a full-time job for one employee because the paperwork, telephone calls, and tracking were very involved. An outstanding local resource for women was the Julie Rogers Gift of Life Free Mammogram program. Women older than 50 with low incomes or a history of special circumstances were eligi-
ble. At first, case managers had to refer the women to the local Gift of Life office, which determined eligibility and referred clients to a local hospital for screening. Soon, the case managers received permission to do the eligibility screening and refer clients directly for the free mammogram. The case managers continue to work with this foundation to provide follow-up care. Conclusion The CM process helps many culturally diverse clients with a variety of physiologic, psychosocial, and emotional needs. The sidebars highlight some of the complex needs addressed in our roles as case managers. During the 3-year grant period, the case managers watched a working definition and model of CM evolve. As demonstrated in the vignettes, we did not always have all the answers, but we were adaptable and persistent in our efforts to provide quality client care—a true indication of client advocacy. Quality CM also manifests in care coordination, teaching and learning outcomes, counseling successes, and seamless health care delivery. Based on clients’ written and verbal responses, our activities were appreciated.
2. Powell S. Nursing case management: a practical guide to success in managed care. New York: Lippincott; 1996. p. 5, 6, 25. 3. Issel L. Measuring comprehensive case management interventions development of a tool. Nursing Case Management 1997;2(4):132-8. 4. Jacobson S, MacRobert M, Leon C, McKennan E. A faculty case management practice: integrating teaching, service, and research. Nursing Healthcare Perspectives 1998;19:220-3. 5. More F, Mandell S. Nursing case management: an evolving practice. New York: McGraw Hill; 1997. p. 68. Donna Wilsker, MSN, RN, Kathy Roberts, MSN, RN, M. Fran Skeels, PhD, APRN, BC, and Cindy Stinson, MSN, RNBC, are all assistant professors at Lamar University in Beaumont, Texas. All authors served for 3 years as case managers at Ubi Caritas Clinic. Fran Skeels continues to provide mental health services to clients at the clinic. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/127985 doi:10.1067/mcm.2002.127985
References 1. Howe R, editor. Fundamentals of ambulatory case management. Gaithersburg: Aspen Publishers; 1998. p. 1-12.
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