Resistance is futile: The case manager as a change agent

Years of training and education experiences have given me (I hope) a broad view of the case management landscape. Regardless of whether we work in the provider or payor sector, there are themes that appear to be common across the spectrum of our practice. Collectively, my experiences contribute to the editorials I have (and will continue to) post here.  Hopefully, these will focus more on the positive aspects of our practice. However, there are the less than glowing issues that we must recognize, evaluate, and correct if we truly hope to see case management continue it’s maturity into a profession of widespread acceptance.  Sure it would be nice to post happy stories about the wonderful work we do week after week but will that approach help us to advance if we are only willing to look at the smiley face of WIIWD? In that spirit, if a topic hits close to home my hope is that it might result in someone taking a look inward to consider if his/her walls are made of glass or perhaps a deck of cards.

Last time, I discussed the issue of complacency. Today’s post pertains to another scourge in our midst, Resistance.  Resistance is that next step on the scale pretty close to complacency in that complacency is more a passive acceptance of the status quo and resistance is an active refusal to accept change.

We have to stop overlooking resistance as a problem in our ranks because it hurts us in multiple ways. The resistor is perceived by his/her contemporaries in a negative light and s/he does harm to the face of case management as a whole because those who look to us to take the lead in coordination of care and resource management are sorely disappointed when confronted by the individual who resists collaboration simply for the sake of not wanting to change. You know the type…

  • The person who begrudgingly completes an urgent task and makes sure everyone know that s/he is doing them a favor
  • The person who mutters about a workflow change and quietly sticks to doing something the way s/he has always done it because that is the right way that it is supposed to be done
  • The person who obstructs rather than facilitates a transition of care because they did not get a form filled out perfectly so puts the request aside and neglects to just pick up the phone to ask a clarifying question
  • The person who skips a team meeting because they are “too busy” and sees their time as more valuable than that of the team
  • The person who enters a patient’s room and announces him/herself as a “case manager” whose job it is to get the hospital paid and the person out the door
  • The person who seems more put upon than flattered when a less experienced case manager turns to them for help with a complicated situation
  • The person who hoards their knowledge and experience and holds it over everyone else’s head to be sure s/he is recognized as the smartest person in the room
  • The person who won’t just come out and speak directly to a colleague about something that is on their mind but rather attributes their feedback to the amorphous collective we often refer to as “they”

Know the type?  Sure you do.  We all have someone we work with that is represented by at least one of those portrayals. Heck, I knew at least one personification of each of those vignettes at every single company I have been an employee of in my thirty odd years working in healthcare. Well folks, that is the person who is killing us slowly in the eyes of colleagues and patients alike. They are a pimple on the face of case management progress and if we hope to grow our ranks with new blood, we need to lance and drain the pustule rather than continue to place warm moist clothes on it waiting for the spontaneous burst.

Resistance is something that we as case managers address with our clients on a day-to-day basis but do we take a close look at ourselves to evaluate how we handle change?  By and large, I believe we do a good job of integrating change but not without grumbling. Don’t get me wrong. I am not saying that we should just lie down and allow the tractor to plow over us unquestioningly. Resistance is normal, but i believe  we can reframe the reason for our resistance into more constructive terms and end up with an even better outcome.

Instead of change being a personal inconvenience, take a step back and think about whether the change is a better, albeit a different way of doing something. Whatever the change impacts, we need to methodically look at the way something is and imagine the way it could be better because two things are for sure 1. nothing in healthcare is perfect and 2. everything in healthcare is changing so resistance is futile.

Sometimes I think that the professional case manager may have been a circus performer in a previous life because the really good ones seem to magically maintain balance on a unicycle perched on an inclined treadmill while keeping porcelain plates spinning all the while. We all know people like this, perhaps we are a person who possesses that amazing amalgam of gifts including (but not limited to) intellect, perspective, reasoning, clarity of communication,  organizational skill, grace-under-pressure patience, roll-with-the punches composure, and compassion for one’s fellow human beings that is brought out in the persona of the honest-to-goodness professional case manager. As I have said before, case management is a symphony of skills, not a solo performance. We have to curtail the diva impulse and keep our eyes on the real priority of our work – our clients.

Be it a change in a workflow process or a change in ourselves, the barrage of competing priorities that have to be juggled will continue unabated. Let’s make a promise to ourselves to always frame our resistance with a reason rather than react and rebuff the revolution at our doorstep.  Case managers are change agents so be the positive light that shines through brilliantly on our practice rather than the negative taste that lingers in one’s mouth like garlic after a big meal.

Until next time… get out there and creatively collaborate!

Complacency and that know-it-all attitude

I was part of a team contracted to train a group of individuals working under the job title of case manager. A majority of attendees were registered nurses but there were a few social workers sprinkled in the mix.  I had been looking forward to the experience for a couple of months and the day had finally arrived.

As we entered the classroom, the first thing that was apparent was that it was crowded. People were milling around trying to find seats and the technical staff was attempting to string together power strips to accommodate the need for plugging in laptops. Despite log ins having been sent out weeks ahead of time, instructors were quickly immersed in looking up numerous usernames and passwords. That was kind of the first red flag that there might be problems because people were supposed to have been practicing with the tools by that point. Well, despite all of the frenzy class began within about fifteen minutes of the scheduled start time.  Though a bit of a rough start, things were still looking good for a very productive day.

Introductions complete, the first instructor launched into the process of transitioning previously taught theory into applied skill. Basic content was reviewed and a video vignette was played on the screen at the front of the auditorium.  It was a large screen and rather hard to miss yet it was obvious that quite a few people were not paying attention.  There was a large group sitting in the back who were blatantly talking throughout the presentation and video, others were responding to email, some were texting on their smartphones or browsing the internet…. but a handful of individuals managed to stay focused despite their colleagues’ extracurricular activities.

After the video was wrapped up, there was an interactive exercise that required people to work in pairs. That was when the muttering started… “This is stupid”, “This is a waste of my time”, “I can’t believe this”, “I know how to do my job”, and so on. As an educator, I am used to a certain level of resistance. I don’t take it personally; it is a normal reaction to change. To the credit of a few, there were individuals who were engaged, clearly grasping the principles, and attempting to work through the case example with the support and encouragement of the instructors. Efforts were made to help steer participants toward resolutions when they seemed to hit a barrier, but frequently the advice was met with an argument or my personal favorite, “I’m just going to do this may way”.  And so day one followed along the agenda and we wrapped up within a reasonable period of the anticipated end time.  The reader’s digest version of day 2 … pretty much a replay of day 1 minus the initial computer problems.

I have spent considerable time thinking about the events of both days trying to determine where disconnects could have been bridged, how material might have been delivered differently, how geo-cultural influences may have had a hand in the situation, and how the class could have been better prepared. What really bothered me was that tens of thousands of dollars seem to have been wasted by an organization that was  trying to provide a learning opportunity to their staff. But the content was dismissed in a rather offhanded manner by quite a few people because they simply could not (or perhaps did not want to) see an immediate applicability of the approach for the patients with whom they worked.

What I saw those two days raised the bar on the level of resistance and obstinacy that I previously experienced as an educator. Even with the benefit of time passing since the experience, I still find myself comparing the behavior encountered to that of stubborn, spoiled children not getting their own way. Though it was discouraging to see a group of reportedly educated clinical professionals conduct themselves in such a manner, the subsequent thoughts gave me even more cause for concern. These individuals, working under the title of case manager, interact with complexly ill, high risk patients. i have to wonder what quality of interaction they experience. I shudder to think of it being anything close to what I saw. It is sad to think that for some people, that is the face of case management. That is a real shame.

I firmly believe this group was a minority and not representative of professional case managers in general. I have the pleasure of knowing hundreds of case managers and they are extremely caring people who are compassionate and poised in all of their interactions. Perhaps the most important characteristic common to those I know is that none of them are foolish enough to believe that they know everything. They keep their minds and their ears open to new concepts and are forever finding better ways of doing things to make their patients’ experiences better than they would be without case management support.

This is a heads up to anyone who feels they are at risk of sinking into complacency in their approach to work. Health care is always changing… consumers expectations are on the rise… and case managers are being viewed by many as a critical factor of successful patient-centered care coordination.  I believe that an overwhelming number of case managers are up to the challenge being placed before them. The essential element that we must remain mindful of is to never fall into the pit of thinking that we know it all or that do not need to consistently and continuously improve the quality of the service we bring to the health care team.

Now get out there and creatively collaborate!

Technology: A Driver of Case Management?

I’ll start off by saying that I am not afraid of technology.

Historically, I have been an early adopter. I definitely see the greater benefit of being plugged in rather than perpetuating the paper trail of life. With that statement out-of-the-way, I have to admit that I am very afraid of a trend that I am watching emerge in case managers across the U.S. It is the growing belief that software is the “process” of case management.  Well folks, I am drawing a line in the sand right here and now.  The resources we access as case managers are a tremendous value-add in how we conduct our work… but the software is NOT THE PROCESS!!!!!  It is simply a tool for how we document the process.

Let me explain…

To my way of thinking, the process of case management was clearly defined and documented by Powell and Tahan (2008) as the following six steps:

  1. Client identification and selection
  2. Assessment and problem/opportunity Identification
  3. Development of the case management plan
  4. Implementation and coordination of care activities
  5. Evaluation of the case management plan and follow-up
  6. Termination of the case management process

The process of case management is NOT about checking off boxes in an electronic assessment in order to produce an automated care plan and canned activities list which is then considered the roadmap for completion of the case management intervention. No… no… no!  That is not what case management is about and it is extremely troubling to me when I repeatedly meet individuals who consider themselves case managers and think that they have cornered the market on case management practice simply because they have figured out how to use their organization’s software program.

What do I believe case management is?  Well, here are a few thoughts to that point…

  • The process of case management is an intellectual exercise in which the professional case manager utilizes his/her gained knowledge and experience to make sound clinical judgements as to what will benefit their client the most.
  • The process of case management is a symphony of skills and knowledge in which the professional case manager examines the unique circumstances of their client’s past and current experience in order to make educated estimations as to their future risks, then proposes desired outcomes and goals, as well as interventions and activities as the means to reach those goals.
  • The process of case management works when the professional case manager collaborates with the client, caregiver, provider, and other members of the healthcare team in order to identify barriers that must be addressed in order to optimize personal health and facilitate reaching maximum potential.

Now, I understand the flip side of systematizing case management tools.  I developed software for case managers. I know having this support is a tremendous timesaver. I know it makes reporting case management interventions and outcomes more straightforward and consistent. It is clearly a value-add in the toolbox of case management… but that is where the distinction must be made.  Case management software is a tool… it is a means to an end, not the end in and of itself.

I have often said that I worry about some case managers losing sight of their soul and forgetting why they got into case management to begin with.  An overwhelming percentage of case managers I know want to help the people with whom they work. The myth that case managers got into the field simply to not have to work evenings and weekends is just plain old garbage and I do not subscribe to that point of view.  However, the frustration created by working under a system where the priority of throughput trumps that of quality is clearly evidenced through the thin smile of an over-burdened case manager. Unfortunately, there are those working under the title of case manager who are simply not really performing the core roles and functions of a professional case manager, as defined by the Case Management Society of America’s Standards of Practice for Case Management (2010).

So keep this in the forefront of your mind… while it may be easy to latch on to a tool in the name of progress and efficiency, that tool will never be a replacement for a kind word or gentle squeeze of the shoulder for those individuals we are privileged to work with.  As a professional case manager, I refuse to allow my years of gained knowledge and experience to be subjugated to the perception of being a computerized caricature driven by a call queue or turnaround timeline.  I challenge each and every one of my colleagues to always find the balance of efficiency to intellect… and to resist the temptation of simply following the trend to productize the professional practice of case management.  We are not bots, our clients are people… and the value of our work can not be captured by a tick in a box.

Now get out there and creatively collaborate!

References

Powell, S.K. & Tahan, H.A. (2008). Case Management Society of America (CMSA)  Core Curriculum for Case Management, (Ed. 2). Philadelphia: Lippincott Williams & Wilkins.

Case Management Society of America, (2010). Standards of Practice for Case Management. Little Rock, Arkansas.