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 Montpelier Magazine

Nursing student Stephanie Wagner takes a blood pressure measurement on a client at the Harrisonburg-Rockingham Free Clinic.  

Medical Monitor

Nurses take over critical need: patients' case management

You have had heart bypass surgery, and five days later you're sent home. Not near enough time to recover? Get used to it. With managed care's emphasis on cost containment, preventative care and more outpatient procedures, hospital stays are short and getting even shorter. So who makes sure you get the care you need while you recuperate?

More and more often, it will be a nurse case manager. "Nurse case management is one of the fastest-growing fields in the health-care industry," says JMU nursing professor Zona Chalifoux. "And in many cases, it's a field in which the demand far exceeds the supply as hospitals, increasingly coming under pressure to deliver the most efficient and cost-effective care possible, are driving the need for case management."

The concept is nothing new in health care, but the scope has changed.

"Traditionally case managers have been social workers," says Chalifoux. "But we're now sending patients home from hospitals and other care facilities more acutely ill than ever before."

These patients require someone with a strong medical background who can coordinate their care, monitor their health and "serve as an advocate - someone who can speak for these patients, who can help them navigate" through the often-confusing maze of health-care systems, procedures and jargon, says Merle Mast, acting head of the nursing department.

Increasingly, that responsibility is falling on nurses, many of whom are beginning to refocus their careers from traditional nursing to case management. Nursing schools and graduate programs, meanwhile, are responding by starting to expand their training in this growing specialty. It's something JMU has already done.

JMU is on the "cutting edge in offering case-management courses" and accompanying practicum experiences for its students, Mast says. "Typically, that's something not often offered on an undergraduate level," Chalifoux adds.

Through a partnership between JMU and the Harrisonburg-Rockingham Free Clinic, some nursing students enrolled in JMU's fall case-management course get hands-on experience in the spring by serving as case managers for the clinic's diabetic patients.

The clinic is one of several sites where JMU students can get their practicum experience. A $117,000 JMU-Free Clinic grant from the Helene Fuld Health Trust in 1999 has strengthened JMU's community outreach and clinical opportunities for nursing students while developing a case-management program at the Free Clinic. Through the grant, students, professors and the Free Clinic staff built and implemented what Chalifoux calls a "state-of-the-art" case-management program that tracks patients and evaluates their progress and the program's success.

Students work at the clinic six hours a day, two days a week each spring semester. Their work offers an intensive, often eye-opening introduction to the realities and challenges of providing coordinated health care to a population struggling just to make ends meet.

According to executive director Ellie Swecker, the clinic has focused its initial case-management efforts primarily on its diabetic patients, who are about 30 percent of the clinic's chronically ill patients. That group was selected primarily because "the diabetic is at risk for eye and kidney disease as well. We try to be proactive by helping to plan for potential problems," Swecker says.

An important component of case management is educating patients about their disease and empowering them to take control of their disease through medication, diet, exercise, and personal and community support systems. The case manager also looks at "what existing resources are available to that patient and what resources are missing," Swecker says. For example, a newly diagnosed diabetic on a very low income may learn that diabetes can be controlled by diet. "But it's hard to eat well on their income, so now let's see if they can qualify for food stamps," Swecker says.

The backbone of case management is holistic care - looking at the entire person, that person's circumstances, resources, abilities and health, rather than just treating the disease, Chalifoux explains.

"Nurses are naturals at that - looking beyond the illness and the symptoms to see the total person and what that person needs to get well and stay healthy," Chalifoux says. "Nurses treat people, not diseases."

By Margie Shetterly