We have all had those cases that were well known to the hospital with frequent overutilization and poor outcomes. I had such a case while providing asthma case management. She met all the common denominators: multiple chronic illnesses and co-morbidities, financial problems, overutilization of non-primary care, complicated with being a single parent, poor work environment, and well-known to be non-adherent. She had frequent ER and inpatient admissions.
After she had a second inpatient admission and was on the ventilator for the second time, I began to follow while inpatient and contacted her after she was off the ventilator and before discharge. As a case manager I was getting frustrated and knew the ramifications of poor adherence. The former discharge plans obviously didn’t work; otherwise there would not be repeat admissions.
This was one of those cases where a case manager gets frustrated because the health care system continued to fail the patient. The phone calls while still hospitalized offered new information and all I did was listen. I had a good relationship with the primary care physician, so I developed and proposed a written discharge plan based on what I heard from the patient. One of main concerns I identified was possible depression. It’s very easy to look at a complex patient and not look at the root cause. The doctor was very open to help with the discharge plan and accepted the new discharge plan and did assess for depression and started her on an antidepressant.
Within a few weeks I noted subtle changes — improved medication adherence, social skills, organization skills, improved energy and sleep habits. Treatment of the undiagnosed and underlying depression was the key underlying root cause of this repeatable cycle of admissions.
She had been labeled by the health care system as a “repeater” but not appropriately assessed and treated. Does she still have chronic illnesses? Yes. But while involved with her the self-management skills became very evident and showed modest change. She contacted her primary care physician before a crisis; she had regular follow-care, and you could see evidence of lifestyle changes.
Even when you feel you are equipped with the best case management skills, it is apparent that listening is the most important aspect. Advocacy is crucial, and unless you push the envelope on this, you may not see the changes. In this case, listening and advocating were paramount in the assessment of depression, and the correct discharge plan instead of the same discharge plans from the past that clearly did not work. I hope that one nurse, one doctor, one patient can learn from this case. Case management was the answer for her, the doctors, the ER staff, hospital staff, friends/family and the payer.
