By Ellen Middendorf, MD- Medical Director of Hospice of Southern Illinois
As the Medical Director at Hospice of Southern Illinois, I use the term “case manager” often in my day-to-day duties. It might be in terms of a request to have the case manager address a medication issue or the case manager follow up on an x-ray or laboratory result. However, I never spent much time considering what case management truly meant for our patients and their families. I just know that the system works, and it works well. However, after a family member of mine suffered a very serious injury in December 2022, I quickly learned that not all compartments of health care delivery operate the same. Even as a physician, I have had multiple struggles navigating our healthcare and health insurance system to get my loved ones the care they need. The process, with all its frustration, made me truly realize the compassion and efficiency of case management.
In terms of CMS regulations, a hospice agency is required to designate a Registered Nurse to serve as a member of the Interdisciplinary Team. Your designated nurse may be referred to as a Case Manager or RN Coordinator. They are responsible for coordinating the implementation of the Plan of Care. Additionally, they may be responsible for offering direct nursing care to the patient and helping collaborate with the Interdisciplinary Team (IDT) for care delivery. CMS recognizes this role as vital as it ensures that care is quality and timely.1
The Case Manager ensures that the Plan of Care remains updated, individualized, and relevant to the needs of the patient.1 This ensures that our patient’s goals are met, and their families and caregivers receive the support they need. But what exactly does this look like in the day-to-day lives of our patients? The Case Manager assesses the patient as frequently as deemed necessary by the IDT. This may be anywhere from once a week to daily. During this assessment, he or she determines if the patient’s pain, or any other medical symptoms, is well managed.
If adjustments need to be made, they reach out immediately to the Hospice Medical Director, Associate Medical Director, Nurse Practitioner, or the patient’s Attending Physician for instruction. At that point, any necessary prescriptions are sent to the pharmacy. The patient and their family are relieved of all the back and forth between providers. And therefore, have a plan for change almost always at the time of the visit.
The Case Manager also investigates the emotional and spiritual well-being of the patient and their family and involves the social worker, chaplain, and/or bereavement counselors as appropriate. The RN additionally sets up the Plan of Care for the Hospice Aide to provide hygiene and personal care. Safety evaluations are reviewed to ensure the patient is receiving that personal care in the safest route possible while preserving dignity. Needs for Durable Medical Equipment, such as wheelchairs, oxygen, and specialized mattresses, are determined. They are ordered for the patient by the Case Manager, and delivery is arranged to the patient’s location of residence. All necessary supplies, such as wound care dressings and colostomy supplies, are ordered and delivered as well.
Furthermore, the Case Manager also arranges for the completion of any forms needed, such as FMLA or Handicap Parking placards. While these are the typical scenarios that arise, our Case Managers respond to all needs of our patients. They are the first line of contact and arrange other services as needed. In a non-hospice setting, the items above would require multiple provider visits, phone calls, and waiting, all adding stress to an often-difficult time.
The process of caregiving is often overwhelming and labor-intensive for the families of those touched by a terminal illness. By removing all the barriers to care that exist in many healthcare areas, our families can feel supported by their hospice care team, and they can develop a trusting relationship with their Case Manager. A Hospice Case Manager is truly an advocate for the care of the hospice patient.
1 Creating an effective hospice plan of care. (2022). Centers for Medicare and Medicaid Services. https://www.cms.gov/files/document/creating-effective-hospice-plan-care.pdf