Standard M: Facilitation, Coordination, and Collaboration

INTRODUCTION

Seamless, smooth transitions of care are imperative in case management practice. The professional case manager recognizes that other providers, organizations, and stakeholders engage with clients and their support network. This may include multiple medical specialties, post-acute providers, payers, and a myriad of other key individuals and organizations. CMSA states that the professional case manager should demonstrate the skills needed to facilitate coordination, communication, collaboration with the client, support network, involved members of the interdisciplinary healthcare team, and other stakeholders to achieve target goals and maximize positive client care outcomes (Case Management Society of America, 2022). With all the technology available, communication among all the interested parties should be easy and hassle-free, right? Let’s explore how case managers are effective facilitators, coordinators, and collaborators.

EXAMPLE

Jake, a Navy service member, was diagnosed with thymoma, a rare malignancy, in 2016. His initial work-up and diagnosis were at a military hospital after experiencing a chronic cough and dyspnea. The military oncologist and PCM determined that the required care was beyond what could be provided at the military facility and requested transfer to the National Institutes of Health (NIH) for further evaluation and treatment. NIH confirmed the diagnosis and recommended surgery with additional chemotherapy. Jake and his NIH team agreed that the University of Maryland thoracic surgery team had the expertise to manage continued care, and he underwent thoracotomy with tumor excision. After four weeks of post-operative recovery, Jake began chemotherapy for six months. Upon completion of chemotherapy in June 2017, the Maryland oncologist recommended radiation therapy to address residual disease. Jake researched and learned that proton therapy could be effective vs. traditional radiation therapy. This led to meeting a radiation oncologist at the University of Pennsylvania who had treated others with thymoma. Jake underwent multiple proton therapy sessions in Philadelphia, living in a hotel adjacent to the hospital. He returned to his military PCM, and oncologist initiated intensive outpatient rehabilitation. Jake had lost 50 pounds during treatment and was determined to return to duty without restrictions.

Regaining his strength and endurance within one year, Jake joined his unit and deployed 12 months later. Fast forward: Toward the middle of the deployment, Jake began to cough and experience breathing difficulties. He was evacuated to Walter Reed National Medical Center, then returned to his PCM and military oncologist, where metastatic disease was confirmed. This led to additional surgery and chemotherapy with the University of Maryland team. In early 2019, Jake sought alternative therapies to enhance his recovery. This included a variety of supplements, vitamins, and other compounds. During this time, Jake transferred his oncology care to an oncologist with expertise in thymoma at Indiana University.

Recovery was slow, and Jake didn’t return to his baseline. An additional diagnosis of a neuromuscular disease, common in thymoma, resulted in an extra team of neurology, ophthalmology, and pulmonary specialists. Eventually, the military healthcare team recommended medical retirement, which was completed in 2024.

Did you identify the various levels of care, providers, and other healthcare professionals involved with Jake’s care? Here’s a brief tally:

• 5 inpatient facilities
• 3 outpatient centers
• 9 medical providers
• 6 case managers

What actions and strategies would the primary/military case manager employ to facilitate and coordinate services, plus collaborate with multiple levels of care during a seven-year journey? How about lessons learned that apply to any case management engagement with a complex healthcare journey?

EFFECTIVE COMMUNICATION=SUCCESSFUL COLLABORATION

Case managers know that promoting effective communication requires more than just using plain language. It requires trust and rapport, based on a care plan with shared goals. A few reminders:

• Appreciate the expertise and contributions of each individual, building respect and trust.
• Identify roles and responsibilities to promote understanding and accountability.
• Sit down, if possible, when meeting with clients and their support network.
• Be open and transparent.
• A shared understanding of preferences, needs, and progress is essential.
• Regular huddles or meetings in-person, virtual, or phone conferences.
• Shared documentation (EMR) that the team and stakeholders can access.
• Address disagreements and conflicts with constructive conflict resolution skills.

Clients, families, and caregivers want to be involved and informed. Advocate for them; their input has equal weight to the healthcare professionals’ knowledge. Collaborative team actions are communicated to the client and their support network, with the case manager present to offer clarification and address questions.

In our example, there were many communication and collaboration interfaces. The multiple providers, facilities, and stakeholders created a maze of phone calls, emails, and secure shared documentation for the case manager to monitor. Organization is key, as information changes frequently with treatment side effects or required services. Fortunately, Jake’s team was very engaged, as demonstrated by direct communication between NIH, the University of Maryland, and his military providers. Jake’s family received regular updates from the case manager, who collaborated with his interdisciplinary team for clear, timely communication. Regular huddles, including Jake and his family, enhanced understanding and adherence to his care plan. Each transition of care or additional service needed a TRICARE referral and authorization, all tracked by the case manager. Jake became his own best advocate through his research and engagement with his entire care team, at every level of care.

FACILITATION AND COORDINATION FOR COLLABORATION

What does it mean to facilitate care? Facilitate means to make something possible or easier. That definition sounds like case management to me. Effective planning creates smoother facilitation, and that planning includes coordination and collaboration. The CMSA Standards of Practice offer “The plan of care, target goals, and client’s needs and preferences are used as a guide for facilitation and coordination of services and collaboration among members of the interdisciplinary healthcare team, client, and client support network” (Case Management Society of America, 2022).

Jake’s journey across many levels of care and providers required that the case manager had accurate input on his wishes, preferences, and goals. His goal was to return to active duty after his initial diagnosis, and every provider, stakeholder, and support person was well aware. Jake wanted to explore additional nutritional support to enhance his response to treatment. Initially skeptical, the military healthcare team did their research and agreed to a referral for a Florida provider and their clinic. The case manager facilitated and coordinated the provider communication to ensure accurate data sharing. In addition, Jake’s command had the resources to secure benevolent funding for reimbursement to the nutrition provider. The case manager coordinated reimbursement from the point of contact with the benevolent organization.

Working across many levels of care and associated providers means keeping your professional network up to date. Effective coordination and facilitation mean that every case manager needs a robust contact list in their email and key contacts on speed dial.

WHAT ARE THE CHALLENGES WITH FACILITATION, COORDINATION, AND COLLABORATION?

Case managers can outline multiple challenges in offering appropriate, value-driven, whole-person care. Consider the following elements in your practice:

• Conflicting preferences and points of view from the client, healthcare team, and stakeholders—how is consensus achieved?
• Technology—help or hindrance?
• Lack of community, regional, or federal resources—what is available and possible?

Communication offers unique problems. Since communication is the hub for facilitation, coordination, and collaboration, case managers must adapt to whatever the situation needs. Consider how the client and their support network want to receive information: in-person, phone call, secure messaging? Is an interpreter needed? Does the client want another person to receive information? A thorough assessment can offer answers to these questions.

For the healthcare team and other stakeholders, how often will meetings occur? When does the payor source want clinical reviews? Clarity is key so that everyone embraces their role and responsibilities. Case managers must be flexible to pivot quickly as information arrives, preferences change, and action is needed. Clear, complete, and concise documentation is essential, especially during transitions of care. Remember that a transition is more than to a post-acute provider; it includes a change in primary care providers or within the client’s current setting, such as ICU to a rehabilitation unit within the same healthcare facility.

The communication paths for Jake’s care evolved into a quilt of phone calls, in-person meetings, telehealth conferences, and so much more. The case manager was connecting providers to the payor source, assisting his family in connecting with out-of-town resources, and helping civilian healthcare organizations appreciate the military mindset that Jake possessed. He had low moments but never lost sight of his goal until his goal changed, while navigating two complex diseases.

CONCLUSION

Case managers are the ultimate advocates, diplomats, and problem solvers. These characteristics are necessary as we navigate an evolving healthcare industry where changing legislation and reimbursement impacts our clients and their support network. Often, case managers have the “macro level” view, while others are experts in their specific area. This translates to the critical execution of facilitation, coordination, and collaboration. Our clients deserve no less.

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