Back when I first started doing case management work, a favorite nurse mentor taught me that case management was different from bedside nursing, as it involved looking at the patient from a viewpoint of 10,000 feet (eagle eye view), instead of 1-2 feet away.  This took me a long time to understand and process, and I still struggle with it from time to time. However, when I find that sweet spot of blending productivity with connecting with a patient’s needs, it’s always because I am maintaining a level view from 10,000 feet as much as possible, the height that many eagles fly while they are scanning the land below.

There are many ways that the vantage point of case management is similar to the vantage point of eagles.  While humans have the ability to have 20/20 vision, eagles have the ability to have 20/5 vision designed for long focus and clarity — about 3-4 times stronger than us. This means an eagle flying at an altitude of 1000 feet over open country can spot an object over an area of almost 3 square miles (according to Peter Nye with the New York Department of Environmental Conservation). The approach to case management is similar in that we consistently scan for patient concerns from a very big-picture, holistic model, while also paying attention to any specific gaps in care that could disrupt a patient’s ability to remain healthy in their community.  For example, a case manager knows that if a patient discharges from the hospital, but is unable to fill their medications at their local pharmacy, they could quickly decompensate and be at high risk for readmission.   

When an eagle sees something on the ground it wants to address, it begins to dive at 60 mph to get closer to the ground.  Case managers do the same thing.  Once we identify a problem, or a gap in care, instead of hoping it will be resolved at the 10,000-foot vantage point, we get involved, and we begin a quick dive to about 5,000 feet.  At this height, we can coach the patient on how to troubleshoot the problem themselves.  We also assess if they have the energy and resources needed to follow an action plan, and if we determine that problem-solving is too overwhelming for them, we drop from 5,000 feet to 1000 feet pretty darn fast.  At this point case managers get to call the prescribers, the pharmacies, and the insurance companies in an effort to resolve a medication access problem as quickly as possible.  

The case manager can then continue this more focused level of care by tracking the concern to completion by confirming with the pharmacist that the medication has been filled and that the patient has picked it up.  This brings me to another aspect of case management I love – making sure the ball doesn’t get dropped, which can so easily happen if a case manager is not involved.  Especially post-discharge, there are so many different ways the ball can get dropped between leaving the hospital and arriving back at home or transferring to a new facility.  Going back to the medication refill example, a clinic nurse may call a pharmacy or pharmacist to make sure they received the prescription, and that they have the order in stock.  But a case manager would go a step further and confirm with either the pharmacist or the patient that they in actuality were able to pick up and start their medication as prescribed.  Tracking to completion, or “closing the loop” are two of my favorite phrases in case management.  This focused level of care has the potential to impact a patient’s entire health outcome and allows us to then go back up to our 10,000-foot view, scanning for more large-scale issues to address.  

Another fun thing about case management is that in addition to keeping the big picture of health as the primary focus, we also get to keep an eye on other things that are not a problem yet, but could become one in the future.  Along with eagles’ massive visual acuity, they also have extraordinary peripheral vision with a 340-degree field of vision.  According to the National Eagle Center, the unique structure of an eagle eye allows them to see things up close and far away at the same time.  They can also see directly in front of them, and to the side at the same time.  Case managers also get to use their ‘peripheral vision to keep an eye on other things besides the main issue at hand.  For example, while troubleshooting with pharmacies, prescribers, and insurance companies about getting a medication filled post-discharge, a case manager is already starting the conversation about the refill process for next month.  We check to see if a 90-day fill is possible, and we check to make sure that there was a smooth hand-off between the hospital provider and the ongoing prescriber to ensure ongoing care. We check for as many barriers to care as we are possible.  What does the copay or coinsurance look like?  Can the patient afford it? Is the patient’s pharmacy close to their home so that it is easy to pick up medications?  Is this medication eligible as a mail-order prescription if the patient struggles with mobility, making it more difficult to get to the pharmacy?  All of these peripheral issues may not be the most immediate need at the time, but we are always keeping our peripheral vision set on potential barriers to care that could impact their overall health in a negative way.  

Another thing I love about case management is perspective-shifting, similar to how eagles’ cornea and lenses allow them to quickly change their perspective between looking at something near and something far away – in a process called “accommodation”.  Case managers do the same thing.  Once we resolve a situation close-up, we immediately resume our 5000 or 10,000-foot perspective, based on what their ongoing needs may be.  We can also toggle quickly between patients who need more close follow-up care and patients who just need a quick check-in to make sure everything is continuing to go smoothly. For example, while waiting on hold to talk to a pharmacist, case managers can review emails regarding other patients’ statuses, research other patient needs/diagnoses/pharmacies, and communicate with colleagues via chat about questions we have about how to best care for a patient.  

The work of a case manager is ever-changing, which means our work never gets dull or monotonous.  We also have real opportunities to impact a patient’s care, make them feel cared about during important transitions in their life, and allow them to relax and heal a bit better because they know someone has their eye on them and is paying attention to their overall care. Especially when patients are at their most vulnerable, eagle eyes can give us the eyes we need to provide excellent case management for all of our patients. 

References:

Human vision vs eagle vision

https://www.insightvisioncenter.com/human-vision-vs-eagle-vision/

National Eagle Center

https://www.nationaleaglecenter.org/eagle-eyes/

Guest post from Susannah Marshall, BSN, RN-BC, CCM, submitted as part of our “Why I Love Case Management” and selected as our 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 :).