Dr. David B. Adams – Psychological Blog

Psychology of Illness, Pain, Anxiety and Depression


Case Management Solution?”  

“Among the many concerns that confront a nurse case manager is finding health care assistance for a patient who:

a. may be simply drug seeking

b. is not truly interested in recovery or

c. sees the injury as an opportunity to end working for a specific employer 

This is especially problematic if the patient was injured years ago in another State.  solution who no longer expected recovery. 

The adjustor may not be privy to the observations and concerns held by the new case manager.  The case manager is, indeed, forced into an intermediary role, assuring quality of care while also trying to establish treatment boundaries. The case manager may also be in the disadvantageous position of educating patient, providers, adjustor and employer, all of whom may have quite different expectations.  

This complexity of roles exists for clinicians as well, but clinicians gather their own data and draw their own conclusions.  Ultimately, they reach a point where they can make the summary statement “there is no more I have to offer this patient.”  And when discharged, the clinician does not concurrently state that the patient requires no additional care. The case manager or the adjustor must inform the patient who will, quite often, question the medical appropriateness of the decision to release him/her. 

Here is one of the most troubling scenarios:  The patient was given access to narcotics for subjective pain.  The patient was known by the original prescribing physician to use medication outside of schedule whether this is through drug screening or pharmacy records. Yet knowing that relocations is imminent, it may be easier to refill these medications than to actively intervene in the misuse of narcotics.  “Let the next person handle this.” 

The patient then relocates.  Much historical information may be lost in this process since concerns are not always forwarded or well-documented. 

New providers develop their own baseline, and it may take months before the goals/intentions of the patient are known.  It is often up to the nurse case manager to obtain the medical records and communicate with the past case manager when possible. 

Not to be overlooked is the positive change/solution that sometimes occurs with a new environment. This change can be the opportunity to streamline care going forward. But the patient may cling to the previous method of case (mis)management and communicating this to all involved may present a weighty challenge. 

From a psychological vantage point, it may be quite clear that the patient has long been in nonproductive care which has become more habit than recovery or solution oriented. 

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