Practice Based Case Management

Do the physicians "buy in" to case management? That's the first thing that needs to happen.

Instead of having the approach of having the patients "change their bad habits", take it one step at a time.

Start simple. For the heart failure patients, have them weigh themselves daily, and when their weight goes up quickly, ask the doctor for a bump up in their diuretic for a few days, and follow up closely. When the patient sees concrete results, they will begin to trust you. For the diabetics, have them check their blood sugars every morning, and then when they are doing that, have them check before breakfast and 2 hours after. Get their blood sugars under tight control, and when their HbgA1C is improved, show them the correlation to controlling blood sugar and the drop in HgbA1C.

When you introduce yourself, don't ask if they want a case manager. Instead, say I'm Joan Smith, the case manager in Dr. Jones' office, and I'm calling to see how you are doing". It's all about presentation.

As you gain their trust, you can increase your management, and you will find that more and more will be open to having you call.

Are you doing an assessment including evaluating their motivation and stage of change? I find that this information really helps me figure out what makes someone tick or not tick. For instance I usually say, "no one wants to have uncontrolled diabetes so tell me why you think your diabetes is uncontrolled." After they tell me why they think theirs is, I come out and ask them, "So are you ready to do anything about that?" If they tell me yes, then I work with them to set a SMART goal(s), if they say no then I give them information about diabetes related complications and their risk. I let them know what is likely to develop if they continue to maintain an A1c of 10%. Ultimately it is their choice whether or not they work with you and while it can be very frustrating, don't give up. Eventually you will find a system that works.