Where did this past year go, and when did it get to be 2003?! I remember hearing that the older you get, the faster time passes by. Well, I must really be getting up there because 2002 was a blur! I hope that the holidays were enjoyable and filled with wonderful and memorable moments for each of you.
Once again we approach a New Year and wonder what it will bring. Of interest, initiatives to standardize case management services appear to be growing. When a process is not well understood, we struggle to make sense of it. When a group of professionals differ in their approaches to assist patients with specific illnesses, we question and challenge the process and the approaches. Why can't there be standardization so that we always get the best results—why shouldn't there be?
Certainly, a reasonable expectation is that case managers want to improve outcomes and be aware of evidence-based guidelines to help attain them. However, most case managers face challenges in the real world in which we work when evidence-based practice outcomes are our goal. Considering the variety of health care professionals engaged in case management and the vast spectrum of practice settings, is it really possible to standardize the process, or do we lose the very essence or art of case management itself when we attempt to standardize our interventions?
Algorithmic and evidence-based practice approaches and the care paths that best meet the needs of most patients in our caseloads truly appear to be disconnected. Cookbook or connect-the-dots methods have application with foods, crafts, and childhood games, but they rarely apply successfully to individuals with complex illnesses. Such methods can contribute a great deal on a limited basis for one disorder or symptom. There surely is an almost perfect way of managing patients with diabetes; after all, we know what kind of care they need, how often they should be seen, the routine tests and examinations.
The patients who find their way to us usually face more than one illness, and often one or two comorbid conditions. How do we use standardized approaches for the patient who has transportation problems, dementia, a language or cultural issue, alcohol or drug dependence, or constant worries about how he is going to pay for insulin and related supplies? The patient who cuts medications in half to make them last longer or has tried but often fails with diet limitations?
There are standards of care, and I am certainly a proponent of case management certification, standardization, and accountability. I also firmly believe in the ingenuity, creativity, persistence, coaching, and heart of the case manager who addresses the full range of issues and solves the problems that are the real obstacles to good outcomes. The true contribution of case management is the acknowledgment of the individual, the difference in each patient, rather than a “what's good for one will be good for all” care plan.
There have been years of discussion and debate regarding the art versus science of medicine and nursing, with final acceptance that they are both. The newer kid on the block, case management, is now under similar scrutiny. Scientific and academic communities need to see the evidence and then develop guidelines for practitioners to better ensure uniform outcomes and predictive modeling tools so we will always know whom and what to manage.
However, we must not sacrifice the invaluable personal judgment, intuition, and instinct born of the one-on-one interaction of case manager and patient in deference to a rigid, standardized process. We should always allow for personal interaction by case managers, a crucially important aspect of our role and our positive outcomes.
The challenge for case managers is to lead our patients (and their physicians) on the road toward excellence, while working within their real world (and ours!). Building the bridge linking ourselves, the health care providers, and our patients and then crossing it is the opportunity and goal for each of us. The bridge itself is the pathway and the art of case management.
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