CMSA Today - Issue 4, 2021

“Good communication skills help to establish trust and rapport. In practice, I find that it is more effective to listen to patients first, then clarify what I heard before responding. This practice creates an opportunity for the patient to partner in shared decision-making versus only agreeing with the healthcare professional.”

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determinants, advance care planning and mental and behavioral health issues enable me to manage my time efficiently to focus on nursing-related interventions. I use data to stratify and identify patients with high-risk chronic diseases. When I identify these patients, I contact them to discuss the availability of case management services to improve life quality, prevent hos pital admissions and reduce out-of-pocket healthcare costs. If patients consent to ser vices, they are placed in a chronic disease management program. Case management services are available to transitional care patients who cannot independently self manage or need ongoing supervision and support. Evidence-based care pathways guide nurse case managers in the manage ment of chronic diseases. Guidelines pub lished by the American Diabetes Association, the Global Initiative for Chronic Obstructive Lung Disease and the American College

of Cardiology are excellent resources for embedded case managers. Knowledge of clinical guidelines improves assessment skills and increases case manager confidence to request provider modifications of the treat ment plan. My encounters with patients are primar ily telephonic. Good communication skills help to establish trust and rapport. In prac tice, I find that it is more effective to listen to patients first, then clarify what I heard before responding. This practice creates an opportunity for the patient to partner in shared decision-making versus only agreeing with the healthcare professional. When I am in the clinic, I typically schedule visits with patients for chronic disease management. Following a comprehensive assessment, case management interventions include educa tion, goal setting and monitoring. I use moti vational interviewing to assess a patient’s readiness for change and to help the patient

establish at least one goal in a session to improve disease self-management. Common patient barriers to disease self-management include a lack of knowledge about the dis ease, its progression, trajectory and com plications. The embedded case manager has an essential role in removing barriers to facilitate patient self-management. Using “plain talk,” analogies and metaphors help patients understand complex pathophysi ology, gain insight into their illness, and increases self-efficacy. The “garden hose” metaphor is just one example of how to explain the effect of hypertension on the brain and kidneys. On a typical day in the clinic, I make TOC calls and serve as a resource to the clinic team. I may help a triage nurse problem solve a complex patient call. A physician might ask me to meet briefly with an unin sured patient during an appointment or ask for advice or assistance with nursing home

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CMSA TODAY

Issue 4 • 2021