It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us.... - From A Tale of Two Cities by Charles Dickens

Recently, I spent the better part of a day holed up in Panera Bread while workers labored away in my home. For some reason, I thought the noise level at the house would be worse than that experienced sitting in the midst of a public restaurant. However misguided I may have been, that is the location in which I was inspired to pen my latest contribution to the Heartbeat of Case Management. I hope that the title and the opening lines will make sense before you reach the last period.

I often say that we all need at least one person to whom we may say anything without fear of judgment, a sounding board of sorts. Blessed am I to have many. My friends outside of the health care field are fairly well versed in the disjointed state of health care. Those hailing from the performing arts, hospitality, coaching, and wine share their points-of-view providing a new lens for me to look through. It is not to say that a traditional perspective is a bad thing, but sometimes it seems to me that our sights have become overly focused on "evidence" as a sort of Holy Grail. Continual reliance on evidence as a barometer for decision making infers our eyes are fixed backward, but does that not risk us running smack dab into bridge abutments as we fail to see what is coming up on the horizon? In any event, my circle is an invaluable source of out-of-the-box ideas in the face of what can be myopic health care groupthink.

In recent years, case management has been feeling the combined pressure of unrealistic expectation overlaid on a basic lack of understanding as to "what it is we do." The need for professional case management is especially pronounced; it is the best of times for those of us in, or associated with, the practice. However, the directions in which case management is pulled (and ripped apart) in order to help bridge care coordination challenges risks the very value of cross-continuum care facilitation that we bring to the table. Arguably, it is the worst of times for those who are in the crosshairs of impractical expectation.

Although privileged to work across the country in a variety of care and support settings, I am also in the precarious position of being on the receiving end of complaints about "case managers" and "case management." Quotation marks appear on those words because more often than not, after inquiring further as to these situations, it is clear that the person at the crux of the issue is not actually performing case management, but rather a derivative of some sort. In some respects, it is the worst of times because everybody wants to say they offer case management, but not everyone actually understands to what it is they are referring.

I praise the commitment of practicing case managers to optimizing the quality of care, life, and function for clients and caregivers. The ingenuity applied to address complex, cross-continuum bio-psycho-social-spiritual care truly inspires me. The age of wisdom ensconced in years of experience and cradled by the commitment to practice standards and professional ethics. Across the spectrum of health care, case managers take a path that is neither well-lit nor well-traveled, in order to care for the countless, sometimes faceless, consumers most likely to get lost in the maze of what has become our national oxymoron, the United States Health Care System.

A system is defined by Merriam Webster as a set of interacting or interdependent components forming an integrated whole. Although integrated is getting quite a bit of play of late, it is not particularly applicable when one takes a macro view of our health care conundrum. Although it may accurately describe specific examples of well-functioning care delivery systems, it does not translate to overall care delivery in the United States. Sad to say, it is the worst of times for far too many ill and injured consumers struggling to coordinate necessary health care and resources.

But not all is dark and hopeless. Sparks fly to light up organizations that are committed to delivering care efficiently and effectively. Case managers working in these environments are fortunate because of the cross-continuum approach to health care. More frequently encountered are the behemoths of care where the door spins so quick that there is scarcely time enough to ask a client's name, let alone to develop a relationship in order to understand the intricacies of the individual-in-environment barriers. This conflict demands that we consider if we are trying to force some square pegs into round holes in referring to every iteration of care coordination as being case management.

On that backdrop, contemplate the case management/case manager conundrum with the following:

* Is it denial in the guise of optimism that is causing us to err on the side of inclusivity in the application of the case manager job title?

* What do we risk by changing the paradigm of meaningful use to how the health care industry overuses both case manager and case management?

* As badly disfigured as these terms have become, do we need to consider entirely new terminology or does that only serve to complicate the situation further?

Perhaps a light shines upon the realization that we may be asking the wrong questions. Although we could continue to despair how circumstances are not what we had hoped and we could continuously debate the misuse of the terms themselves, it is not the best use of our talents. Needed is ongoing stakeholder discussion with regard to case management reform in order to save the credibility of what we hold most dear-the concept of professional case management practice. As humans, we are a complex, and sometimes strange, lot. We can be kind and generous or cruel and greedy. Although we may be at our worst in the best of times, we are most definitely at our best in the worst of times. How we, as case managers, evolve now will set the tone of our legacy. At this time in history, we really do have everything before us.