Case management and the new nephrology social worker

Social workers bring a unique understanding of “person-in-environment fit” to case management. With this understanding of the interaction of the psychological, social, cognitive, and biological factors that shape health behavior, nephrology social workers are a valuable asset in the case management of chronic kidney disease (CKD) patients. The skills and resources to help patients identify and resolve problems are just as important.

Success in case management involves balancing the needs of the patient, the facility, and the staff while coping effectively with the tensions involved in meeting these sometimes conflicting demands.¹ This balance is needed as the nephrology social worker intervenes on multiple levels with various “customers.” Nephrology social workers use case management to achieve patient-centered outcomes by triaging, mobilizing, and coordinating service delivery. The goal of case management is to promote quality of life and maximize functioning for patients with CKD.

Micro and mezzo case management

Micro-level case management such as behavioral management, family/caretaker support, health promotion, illness management, rehabilitation, and adherence counseling are all a part of case management on an individual level designed to lessen barriers to positive treatment outcomes. Nephrology social work case management utilizes creative energy within organizations to develop innovative and efficient new approaches to service delivery.

Time is precious to each discipline on the team. Nephrology social workers, like other team members, experience an abundance of patient need in their caseload against limited time to serve those needs. The way a nephrology social worker uses time is also precious to the bottom line of the organization. As such, social workers often engage in micro and mezzo case management simultaneously.

Mezzo case management involves small-to-medium sized groups and/or local organizations. Examples might include focusing on an institutional or cultural change rather than individual patients, or management of a social work organization or advocacy for patients within a community, such as securing access to community psychiatric and physical therapy services. Mezzo case management ensures that the needs and barriers of individual patients are understood and taken into consideration within the context of larger social issues.

Applying macro levels of case management is a time-saving strategy. The recognition of a problem or trend can be identified in your patient population. For example, quality of life measurement can help to identify depression or barriers to attending treatments. From that QOL data, a project can be customized to fit the needs of several patients at one time at a dialysis or transplant clinic. Such projects include depression management, fluid management, rehabilitation groups, missed treatment projects, etc.

Macro case management empowers patients by involving them in systemic change and it is a key distinction between social work and other helping professions because it uses social work’s knowledge of systems theory.³Macro level interventions can move into improving patient outcomes on a very large systems level, such as:

Advocating for patient needs in current health care reform legislation

Teaching patients/families to advocate on their own behalf within the larger system

Advocating for care coordination between agencies at the local, state, and national level

Whether working at the macro, mezzo or micro level, maximizing time efficiency is important. The ability to effectively identify psychosocial barriers that impede treatment outcomes, locate resources, mobilize systems and provide directed clinical counseling interventions to reduce are essential to maximize outcomes in the care of the ESRD patient.

Strategy and focus are fundamental in managing the routine and crisis requests/needs that arise in a clinic setting each day. When seemingly urgent tasks relating to transportation, transient arrangements and insurance are shifted away from the social worker, the efficacy of social work case management can be proactive and more productive to the needs of the clinic. Steven Covey described a system for prioritizing work that is aimed at maximizing long-term goals.² This idea can be used to maximize the goals of the patient, the institution, and the staff. In nephrology social work case management, the idea of “putting first things first” is driving a gradual shift to macroprogramming.

When setting up a case management practice as a new nephrology social worker, it can become easy for others to sense your need “to belong” or your desire “to help.” It is important to avoid the pitfall of letting this guide your professional practice. Staying objective and measuring your case management outcomes will keep the nephrology social worker focused and help him/her make the best use of their time while juggling urgent casework, routine casework, documentation, QAPI, program development, and social work collaboration with the team. Educating the team on your roles in social work case management is important. Providing details to your manager on workload and unmet patient needs can be very important in making decisions related to staffing and assignment of administrative tasks. Having a firm foundational knowledge of the National Association of Social Worker’s (NASW) Code of Ethics will help the nephrology social worker explain scope of practice surrounding legal and risk management issues to management.

Summary

Case management is thought to be an effective way to offer counseling services and integrate the coordination of other services ⁴ into an efficient care delivery model. Through communication, collaboration and outcome-driven interventions, nephrology social workers can make a difference in health risk behaviors through case management. ⁵-by Mary Beth Callahan, ACSW, LCSW

References

1. Mizrah T, Berger CS. The effect of a changing health care environment on social work leaders: Obstacles and opportunities in hospital social work. Soc Work.2001 Apr; 46 (2):170-82.

2. Covey S. The seven habits of highly effective people. New York, NY: Simon & Schuster, 1989.

3. Morrow-Howell N. Clinical case management: The hallmark of gerontological social worker. Journal of Gerontological Social Work, Vol. 18, Issue 1-2, 1992.

4. McKinley M, Callahan MB. Utilizing the case management skills of the nephrology social worker in a managed care environment. Journal of Nephrology Social Work,Vol. 18, 1998.

5. Maldando S. Macro, mezzo and micro social work, www.SocialworkLicenseMap.com, accessed March 3, 2014.