Part 3 of a 4-Part Series.
Earn 2.0 CEUs for this e-learning opportunity.

Ensuring that patients will participate in their recovery after a disabling illness or injury can be a difficult task initially. Case managers working with the patient must have a knowledge of their disabilities, be proactive and self-directed, and have a holistic approach in the caring for the patient.

 

However, case managers can ensure that patients participate in their recovery by providing education, identifying care needs for training, and coordinating services and support to patients, family, and staff in the inpatient rehabilitation setting. The education the patient receives should be individualized and specific to the injury, which allows the patient to be better informed on how to care for the condition, which may include medication management, nutritional management, bowel and bladder management, skin care, and self-care as a few examples.

 

A case manager also collaborates with interdisciplinary team members to ensure that the family is well trained to care for the patient at discharge, usually addressing the same issues. If patients have more knowledge, they can better advocate for themselves to ensure they are receiving the appropriate medical care, supplies, and equipment needed for their care.

 

Coordination of services includes making the appropriate referrals for continued therapy in the various settings, such as home health or outpatient; consulting various services to meet medical care needs such as monitoring of labs; providing wound care; providing nutritional or enteral feedings; collaborating with the social work team to ensure the patient has the resources to procure recommended services; and ordering medical supplies that may be needed, such as urological supplies, tracheostomy supplies, and wound care supplies.

 

Case managers advocate for their patients by making sure the appropriate information about their condition and care is given to the patients and families, by being “a voice” for the patient when they feel they are not heard, encouraging a sense of independence in the patient, and

promoting involvement. If patients are involved in the goal setting, they tend to be more invested in their care and are better able to direct their care.

 

Case managers can best meet the medical care needs of patients with a SCI or other disabilities by ensuring continuity of care upon discharge and connecting patients and their families with community resources to receive continued aftercare services. This is especially true when dealing with the indigent population.

 

For example, when a patient with no insurance was being discharged and needed monitoring of labs for medication management, oxygen and other respiratory supplies, enteral feedings, and continued therapies, the nutritional support team within the facility was consulted to order the feedings, using funds allocated by the facility, and to educate the patient and family on how to administer the feedings.

 

The respiratory supplies were ordered using the same funding. The patient was also able to be scheduled for continued therapies at an outside facility that can provide scholarship assistance

to patients without insurance, despite this being a program of very limited resources. One way to ensure continuity, in particular, is to make sure the patient has a primary care physician so that all pertinent information is relayed and the patient can be followed to avoid recidivism when possible.

 

A case manager in the inpatient setting also helps to meet the psychological needs of the patients and families in adjusting to injury and illness and the discharge home. The case manager collaborates with team members, especially social work to identify additional gaps in service delivery and caretaker concerns. The patient’s anxiety levels tend to increase as the time to discharge gets closer, and that is when the case manager can step in to ensure that the patient has the knowledge, appropriate training, and equipment/supplies needed for a smooth transition and continuity of care. Providing support in the preparation of discharge to the community is an important step in ensuring a smooth transition home and quality self-care after discharge, while also decreasing anxiety and providing some sense of control to the patient.


Continue reading >> Life After Spinal Cord Injury: Case Manager Perspective II

Earn 2.0 CEUs for this e-learning opportunity.