Advocacy and the Care Manager

by Stefani Daniels, Managing Partner
Published on Sep 07, 2016

Although multiple factors influence the need for advocacy, it is generally true that someone in the hospital environment must assume the role of patient advocate, particularly for the patient whose self advocacy is impaired or a family that lacks healthcare literacy. The core condition which demands advocacy action is the vulnerability of the patient in two respects: personal vulnerability from illness, and vulnerability to risks inherent in the institutional processes to which the patient is exposed in the health care system.

Our post of August  22, Three Easy Pieces, drew many responses to item 1 in our email inbox.  Most were quite complementary and endorsed the concept of the hospital case manager as the patient's primary advocate, but some challenged the idea that an individual hospital care manager has the ability to change performance expectations without the support and help of the program's director.  For those doubting Thomas' allow me to refer you to Hussein Tahan's refreshing two-part article on the Essentials of Advocacy in Case Management that appeared in the July/Aug and Sept/Oct 2016 issues of Lippincott's Professional Case Management journal.  In Part I of the article Tahan lays out the conceptual model of advocacy as a core competency of case management practice across practice settings. He guides the reader into the contextual meaning of advocacy and describes it as a "moral and ethical obligation that can be evident in the decisions and actions of case managers." Those words echo the words I have used for many years in presentations, training programs and pitching consulting services to a C-suite audience.  "Advocacy", I've said, "is the care manager's primary ethical obligation."

The questions posed by some of the email writers seems to infer that serving as the patient's advocate conflicts with the performance expectations of their care manager roles. But I don't see it that way.  Even if the model of hospital care management is the traditional second generation, task oriented model, the care manager, tasked with one or more of the services typically provided by case management departments, is still obligated to identify what may or may not be in the best interest of the patient.  It means that if the care managers are responsible for the utilization review function, they would make sure the patient really needs hospital level of care.  As an advocate, they know that every hospitalization carries risk and unless the benefit of hospitalization outweighs the risk, alternatives for needed care should be discussed with the patient and care team.  Similarly, when the care manager is making rounds with the physician and notes that the physician is ordering a repeat test, the proactive patient advocate will inquire about the value of repeating the test. And if the care managers are responsible for discharge planning and discharge arranging tasks, the proactive advocates won't wait till a physician writes an order but will anticipate the patient's post acute needs soon after admission and begin to get the wheels turning to explore all possible alternatives knowing full well that every day the patient remains in the hospital unnecessarily adds a high degree of  risk.

These proactive advocacy acts do not require a new job desription or nor do they indicate a change in performance expectations; they are inherent to the title 'case manager.'  However, I will acknowledge that program Leaders often fail at instilling this virtue into the heart and mind of their case manager associates.  As Tahan writes, it is unfortunate that "case management leaders have not yet fully recognized the importance of client advocacy as a priority role of the case manager."  Based on my travels to hospitals across the country, this assessment rings true. Far too many leaders are the result of internal promotions and in my experience, the highest performing individual in the department often becomes a poor manager.  Why?  Because it's diffcult for them to let go of work that they were trained to do and which they did very well and brought them to the attention of senior leadership in the first place.  In contrast, good managers have learned how to assign work to others, motivate and coach personnel, promote a culture of advocacy and patient-centeredness, and provide feedback about performance instead of putting out fires and handling the tasks themselves.

It would be great if every Leader promoted our advocacy obligation and reinforced it by example. But in the absence of such guidance, each individual bearing the title Case Manager must independently enhance, elevate and improve their skills in order to help patients navigate the increasingly complex world of healthcare. With advocacy as their guiding principle which, together with their experience and personal strengths, hospital case managers can ensure that every patient under their care receives the right care, in the right place, at the right time.