Case Management is…meeting a hiker on a mountain in the wilderness who has a sprained ankle, no flashlight, and is running out of water – and figuring out how to best get them back to safety using the skills and resources they already have — while also assessing the situation and finding additional supports and services needed.  

A Case Manager (or “Hiker Support Specialist” (HSS)) surveys the land and looks and prepares for obstacles before offering to help (reviews medical records and utilization history, speaks with providers, etc).  

The Case Manager/HSS then approaches the hiker and asks them how they are doing, if they need help, and asks them where they are trying to get to (compassionate care, motivational interviewing, goal setting, and rapport building by exploring the patient’s needs).  The hiker explains that they are staying with their uncle and cousins at a campsite 2 miles away, and they just need to get back to them (establishing goals needed for the treatment plan).  

The Case Manager/HSS and hiker look at the map together, and map out the path the hiker needs to take to get back to the campsite (collaborative care, exploring and assessing the patient’s needs, etc).  The Case Manager/HSS asks the hiker to re-trace their steps – have they hiked this path before?  Have they had this kind of obstacle before?  How did they resolve it the last time something like this happened (strengths-based approach to problem-solving, drawing on the patient’s already established skills and inner wisdom)?

The Case Manager/HSS then asks if it is ok for them to look at the hiker’s ankle (consent to care).  The CM/HSS assesses the ankle, sees if they can put weight on it and if they are able to able to be mobile with or without support (patient assessment of ADLs, building care plan).  The CM/HSS also determines if they are in too much pain that something more serious than a sprain has occurred, and explores the possibility of needing emergency rescue/airlift (further assessment, escalation of concerns to appropriate providers).  The hiker and CM/HSS determine that limited weight can be placed on the ankle with supportive care/someone to walk with (CMs do not ask patients to do more than they are capable of doing, but encourage them to do as much as they possibly can under their current circumstances).  

The CM/HSS asks to see what the hiker has packed for his hike by exploring their backpack.  The CM/HSS notices that the hiker has a compass, water filtration system, cell phone, and a flare gun.  The hiker states that they had forgotten that their dad had packed an emergency cell phone and that since they were only 2 miles away from the campsite, may have limited cell service they can use to call them and ask for them to come pick them up in their truck (utilizing current resources before adding new resources, problem-solving, exploring additional resources and social determinants of health).  When the uncle arrives to pick the hiker up,  the hiker uses their uncle for support to get to the truck (following treatment plan to do supportive movement only).  

The CM/HSS stays with them, watching the hiker move slowly, monitoring progress as they start to put a bit of weight on their ankle, and adjusting support as needed (monitoring and revising care plan).  As the hiker gets into the truck, the CM/HSS asks the uncle if he feels confident getting him back to the campsite and getting him additional medical support as needed. The CM/HSS confirms that the uncle has enough gas in the car, a working cell phone, and emergency numbers as needed (exploring potential barriers to care, safety planning, advocacy).  The CM/HSS wishes them all the best and continues hiking until they meet another hiker that may need support. Rinse/lather/repeat.

I believe the most important thing a Case Manager can do for a patient/hiker is to empower them to meet their own needs as much as they are capable, and then advocating for them the rest of the way.  It is so important that we not overwhelm or push them beyond their current limits, as this can be disempowering, and potentially cause harm or be traumatizing.  Sometimes this requires doing a little extra work for them (calling clinics on their behalf to get an appointment made, conference-calling with them to their provider office or pharmacist to get the medications they need) until they are stabilized – which is the advocacy part.  The trick is finding that sweet spot between ease, challenge, and overwhelm.  If we build a treatment plan around the skills they already have, and use approaches that they themselves have stated have worked for them in the past, we build that sense of empowerment and confidence within them that promotes healing and sustainable growth (hopefully beyond the time we are providing CM support so that we are not creating a false sense of dependency).  When we advocate for our patients, this also role-models what advocacy looks like to patients who may have never had anyone advocate for them before, or do not understand how to best advocate for themselves.  It also shows them that they are worth fighting for so that they feel confident doing this for themselves the next time they need to ask for help or support.

In addition to empowerment and advocacy, it is the Case Manager’s job to always keep their eye on health equity using a trauma-informed care lens.  What if this hiker had been lost in the woods when they were a child? What if their mother had died in a mountaineering accident?  What if the hiker was 2 miles away from his uncle for a reason unexplored (did he feel safe around his uncle, etc.)?  These are all things that as case managers we get to assess from a birds-eye view, with a holistic approach.  We get to investigate while being compassionate.  We get to think outside the box while being systematic (following trauma-informed care recommendations).  We get to ask important questions, and we get to problem-solve.  Case management is taking a 360 view of a patient’s healthcare and social needs, figuring out what the barriers to care are, exploring if there are any additional hidden barriers to care, empowering them to build off of their established strengths to launch them back into health (or as close to it as they can get), and then advocating our butts off for them the rest of the way.  Case management is an awesome job!

Guest post from Susannah Marshall, BSN, RN-BC, CCM, submitted as part of our “Case Management Is… Contest” and selected as the Second Place Winner!

My name is Susannah Marshall, and I am a board-certified case manager, as well as a board-certified psychiatric Nurse. I have been in healthcare for 7 years and worked in social services for about 10 years prior to becoming an RN. I love all forms of partner social dancing, including waltzing, Argentine tango, and West and East coast swing dancing :).