CMSA Today - Issue 3, 2018 - 7

P R E S I D E N T 'S L E T T E R

Patient-Centered Plans and
Authentic Case Management
BY MARY MCLAUGHLIN-DAVIS, DNP, ACNS-BC, NEA-BC, CCM

KINGA/SHUTTERSTOCK.COM

R

ecently, I sat with a fifty-eight-yearold stroke patient at a skilled nursing
facility (SNF). The patient had a history of alcohol abuse and smoked a pack of
cigarettes a day. He had a wife, five sons and
a granddaughter. The patient had significant
deficits from the stroke, and the potential
for his returning home was poor. Based on
the patient's medical picture, it appeared
it would be relatively easy to write a care
plan and create the goals to match the plan.
When I asked the patient what he would
like to accomplish, he replied, "Rest. I'm
so tired, and I want to see my son and my
granddaughter."
There are frequent references to "patientcentric care plans" in health policy, health
care standards and case manager literature.
Case managers promote patient- or clientcentered plans as a necessary component
for authentic case management practice
(CMSA 2016).
The challenge for case managers is to
step back and allow the patient and his designated caregiver to create their own care
plan and define their subsequent goals. This
may require a change in paradigm for the
case manager who previously directed care
and set the goals for the patient care plan.
At the heart of a patient-centric plan is the
relationship between the case manager and
the patient. The case manager learns the
patient's priorities, and the patient learns to
trust the case manager. The mutual respect
within the relationship allows the patient
to design a personal plan of care and to set
goals for the plan. The patient's plan and
goals may not be directly related to curing
disease or health promotion, but the astute
case manager will align the patient's goals
with health-related goals.
Our SNF patient was reclusive, and until
his stroke spent all of his time at home with
his wife, with periodic visits from his son's

family. The familiar routine was abruptly
disrupted, causing confusion and sadness for
the patient. We confirmed with him that his
therapy regime was exhausting and that he
was homesick. With the patient and his wife,
we developed a short-term plan for rest periods between his scheduled therapies. We
also created a large schedule for the bulletin
board with the dates the family would visit.
The long-term plan was continued therapy
for function and strengthening, with scheduled rest periods. The patient maintained his
calendar for family visits and explored with
his family the possibility of returning home
with skilled and community support, as well

"At the heart of a patient-centric
plan is the relationship between
the case manager and the
patient. The case manager learns
the patient's priorities, and
the patient learns to trust the
case manager."

as his commitment to maintain abstinence
from tobacco and alcohol.
The patient-centric plan requires a relationship between the patient, the case
manager and the interdisciplinary team.
The case manager is the patient advocate,
and it is incumbent on her to listen to the
patient and connect his plan and goals to
plans that lead to the personalized goals of
improved health. ■
REFERENCE
CMSA, (2016). Standards of practice for case management, revised 2016. Case Management Society of America.

Mary McLaughlin-Davis, DNP, ACNS-BC,
NEA-BC, CCM
President, CMSA
2016-2018

Dr. McLaughlinDavis is the president
of CMSA. She has
been a certified
case manager since
1993; she is a clinical
nurse specialist for adult health and the
senior director for care management for
Cleveland Clinic, Avon Hospital.
DIGITAL * Issue 3 * 2018

CMSA TODAY

7



Table of Contents for the Digital Edition of CMSA Today - Issue 3, 2018

President’s Letter
Association News
CMSACorporate Partners
The Opioid Epidemic: Understanding the History and Confronting the Impact Today
Accountable Care Organizations and the Impact on Care Management
Case Management in Primary Care Makes a Difference
Past Presidents Corner
The Integrated Case Management Program: Essential for Today’s Case Manager
Index of Advertisers
CMSA Today - Issue 3, 2018 - Intro
CMSA Today - Issue 3, 2018 - cover1
CMSA Today - Issue 3, 2018 - cover2
CMSA Today - Issue 3, 2018 - 3
CMSA Today - Issue 3, 2018 - 4
CMSA Today - Issue 3, 2018 - 5
CMSA Today - Issue 3, 2018 - 6
CMSA Today - Issue 3, 2018 - President’s Letter
CMSA Today - Issue 3, 2018 - Association News
CMSA Today - Issue 3, 2018 - 9
CMSA Today - Issue 3, 2018 - 10
CMSA Today - Issue 3, 2018 - CMSACorporate Partners
CMSA Today - Issue 3, 2018 - The Opioid Epidemic: Understanding the History and Confronting the Impact Today
CMSA Today - Issue 3, 2018 - 13
CMSA Today - Issue 3, 2018 - 14
CMSA Today - Issue 3, 2018 - 15
CMSA Today - Issue 3, 2018 - 16
CMSA Today - Issue 3, 2018 - 17
CMSA Today - Issue 3, 2018 - Accountable Care Organizations and the Impact on Care Management
CMSA Today - Issue 3, 2018 - 19
CMSA Today - Issue 3, 2018 - Case Management in Primary Care Makes a Difference
CMSA Today - Issue 3, 2018 - 21
CMSA Today - Issue 3, 2018 - 22
CMSA Today - Issue 3, 2018 - Past Presidents Corner
CMSA Today - Issue 3, 2018 - 24
CMSA Today - Issue 3, 2018 - 25
CMSA Today - Issue 3, 2018 - The Integrated Case Management Program: Essential for Today’s Case Manager
CMSA Today - Issue 3, 2018 - 27
CMSA Today - Issue 3, 2018 - 28
CMSA Today - Issue 3, 2018 - 29
CMSA Today - Issue 3, 2018 - Index of Advertisers
CMSA Today - Issue 3, 2018 - cover3
CMSA Today - Issue 3, 2018 - cover4
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