I am a hospital-based outpatient case manager in a rural area. In February 2005, a 52-year-old woman was referred to me for case management. The patient was referred because, I was told, “She is not compliant and hasn’t kept any of her appointments for the last six months.” This was the beginning of a three-year relationship that I believe changed both of us.
When we met, this woman, whom I’ll call Jane, had multiple myeloma requiring thalidomide and decadron, diabetes requiring high doses of insulin, renal insufficiency, anemia requiring epogen three times per week, aortic insufficiency and CHF, and was s/p repair of orthopedic anomalies which made it difficult for her to ambulate. She was edentulous and had a speech impediment that made it difficult to understand what she was saying. Jane also had mild mental retardation, however she was her own power of attorney. Jane lived with two siblings, but both worked full time and did not understand the extent of her medical problems and needs.
I quickly realized that her failure to follow her physician’s plan of care had nothing to do with non-compliance. The cause was actually twofold. First of all, she had so many medical providers it made my head spin! Jane was supposed to keep track of appointments with her PCP, oncologist, Tuesday’s oncology clinic, cardiologist, nephrologist, endocrinologist and diabetic educator. I was overwhelmed! Secondly, she depended on the state-funded transportation assistance for rides to and from medical appointments. Her speech made it difficult to call to get rides.
Jane and I met, I assessed her needs, and she agreed to case management. She quickly developed trust in me and I became her advocate and liaison. I made all her medical appointments, arranged for rides and put these on a calendar which she kept on her refrigerator. I attended her appointments with her as often as possible. This allowed me to reinforce teaching, review her care plan and share any new information with specialists and PCP.
After discussing with Jane and physicians, we changed PCP to the same internal medicine physician who treated her at Tuesday’s oncology clinic. This was one less person involved and one less appointment to get her to. We changed her three-times-per-week epogen injection to every other week aranesp. I facilitated treatment with a dentist and got her dentures. Jane never missed another appointment. One sibling realized how involved her medical care was and became extremely involved in her care. I cherish the times we spent talking, especially at Tuesday’s oncology clinic. No matter what life throws at her she is always happy.
Today, her multiple myeloma is in remission and her renal function has improved. Dialysis is no longer imminent. “Jane’s” functional status has recently declined, and so she is now living in an LTC facility. We keep in touch by cards and letters and I share these with her PCP and other former providers.
Jane wasn’t non-compliant. Jane just needed a case manager.
