By Heidi Steinhebel RN, BSN, CCM
I began my case management journey working with catastrophic patients who primarily had a cancer diagnosis. It required me to quickly become well-versed in various diagnoses, learn about the different tests needed throughout the treatment period, and understand the complex treatments for those cancers. I was doing research, focusing on that primary diagnosis and how to manage it. My actual goal was to provide education to the patient on the cancer diagnosis and treatment options, research ongoing alternative studies, and aid them in managing their symptoms and following their care plan. It was important to me that patients clearly understood the diagnosis they faced, the treatment options presented, and felt empowered to participate in the decisions made. I always did an assessment, but co-morbidities were often not addressed thoroughly, as the complexity and urgency of the primary cancer diagnosis were my priority.
One day, I was visiting one of my patients for a physician appointment, and he started talking about his medical history and the difficulties he was having managing it. He was still checking his blood sugars and trying to eat healthy to stay on track with his diabetes. He felt that he was not successfully managing his disease, and this was creating a sense of loss of control. He knew he had no control over his cancer and the treatment, but he still felt that he could impact his diabetes. After the visit, I started to really think about his journey and his desire to manage his diabetes, something that I had not really thought anyone with a cancer diagnosis would be focused on. It is true that for most cancer patients, the management of other chronic conditions takes a backseat and is usually not even addressed by their physicians.
I knew I needed to think about the medications and treatments, such as steroids and radiation, that these patients are undergoing, and how this impacts a patient's day-to-day:
- Blood sugar fluctuations: chemotherapy and steroids given during treatment often cause blood sugar spikes (hyperglycemia) and, occasionally, drops in blood sugar (hypoglycemia), as well as increases in blood pressure (hypertension) and fluid retention. Close monitoring and medication adjustments are needed.
- Appetite is impacted, and this can cause barriers to patients taking their medications as prescribed due to loss of appetite and nausea. This can lead to dehydration and irregular bowel patterns.
- Chemotherapy medications affect the efficacy of some medications.
- A dietitian can support patients in addressing many of the symptoms caused by the treatment.
- Wound healing is affected by high sugar levels and immune compromise.
I was determined to step back and reassess how I was looking at my patients, reprioritize the things on my “to-do” list, and let the patient tell me what was on their “to-do” list. At our subsequent visit, I talked with him about making a list of things that were important to him, what was going well, and what he wanted to work on, and developed a list:
- He talked to his primary care physician, and they were able to adjust his medications so that he felt he had control over his sugars.
- He met with the dietitian at the oncology center to discuss how he might adjust his diet, ensuring he had the protein he needed due to a reduced appetite.
- We strategized about his daily routine and how he could capture time each day when he was feeling his best to do the most important things, without feeling he had to do everything.
I learned early on that being a care manager really required a holistic look at the patient, not being so focused on the primary diagnosis, and really talking to the patient about what they were most worried about, not assuming based on my agenda. We all know our patients are undergoing tremendous stress, uncertainty, and confusion, but they also want to maintain some sort of routine, power, and their health. It is imperative that we set aside our own agenda and really listen to what they want and what worries them most. It is not until we hear them that we can help them.
How are you listening to your patients?
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Bio: Heidi Steinhebel RN, BSN, CCM, serves as the Sr. Associate Director of Care Management at Trinity Health IHA Medical group. With over 26 years of experience in case management, Heidi has played a pivotal role in designing and implementing comprehensive care management programs in organizations including Blue Cross and Medicare. She is recognized for her leadership in building interdisciplinary care teams- incorporating dietitians, pharmacist and specialty care managers to promote a team based approach to patient care in the ambulatory setting.
Heidi is a current board member and former secretary of the CMSA Detroit chapter. She has spoken nationally, presenting on topics such as advanced care planning, patient activation and case management of heart failure patients.