For years, the health care system has tried to encourage and empower people to not only participate in, but also direct, their care and treatment. Although this mindset is preferable to the paternalistic models of the past, in which people followed, sometimes unquestioningly, the decisions made by health care professionals, a shift in thinking around empowerment is not sufficient. Individuals need in-depth, specialized knowledge about their chronic conditions and other life-altering health issues before they can make informed decisions.
In primary and specialty care settings, information and empowerment are being taken to the next level by providing a variety of tools for people with chronic conditions or who are dealing with the sudden onset of a disease such as cancer. Delivery of these tools-often, online resources and other consumer/patient information-is typically the responsibility of the professional case manager, preferably one who is board-certified. Through these tools and resources, the professional case manager facilitates two key approaches: shared decision making and self-management support.
* Shared decision making (SDM) emphasizes collaboration between the individual and care providers to make health care decisions together, in alignment with the person's goals, values, desires, and preferences. While utilizing the care provider's expertise, SDM acknowledges and honors the individual's right to be fully informed and to determine his or her health goals.
* Self-management support (SMS) provides individuals with the information, resources, and other data they need to make health care decisions and manage their health on a day-to-day basis. As a means to educate and empower, SMS encourages individuals to learn more about their conditions and take an active part in their health care. (Agency for Healthcare Research and Quality, 2014, p. 1)
Together, SDM and SMS represent the next level of individual empowerment around health care decision-making and self-care. Rather than merely shifting responsibility to individuals and/or their support systems/family, the emphasis is on education so that people understand their diagnoses, prognoses, and care/treatment options. With greater understanding, individuals are more likely to be compliant and thus realize improved outcomes.
To be effective as a health care approach, SDM requires that clinicians accept the underlying ethical principles of self-determination and autonomy (Elwyn et al., 2012, pp. 1361-1367). Here, too, the role of the board-certified case manager is crucial, as illustrated by the Code of Professional Conduct for Case Managers from the Commission for Case Manager Certification. The Code states that "case management is a means for improving client health, wellness and autonomy through advocacy, communication, education, identification of service resources, and service facilitation" (Commission for Case Manager Certification, 2009, p. 3).
To educate individuals, online tools and resources such as WebMD (http://www.webmd.com/) or reputable health care sites such as Mayo Clinic (http://www.mayoclinic.org/patient-care-and-health-information) have existed for years. What is different now is a formulized process by which individuals are given access to such websites and other information meant expressly for them, which is then incorporated into an SDM model.
SDM and SMS in Action
Knowledge is truly empowering when it comes to the individual's involvement in managing serious and chronic health issues. While short, intermittent physician office visits can provide some support, the in-depth knowledge that facilitates SDM and SMS cannot be delivered during a typical physician office appointment or during a half-hour session with a counselor or nutritionist. Information and support must be ongoing and in-depth to help individuals gain a fuller understanding of their health status, treatment and care options (including the pros and cons), and other related issues.
Tools can also provide support via health monitoring, from blood pressure cuffs with telemonitoring capabilities to weight scales that enable individuals with congestive heart failure to gauge the amount of fluid retention. Whatever the tools employed, the objective is to put as much information into the hands of individuals so that they take control of their self-care.
Consider the example of "John," who has been told that diet and exercise are important for controlling his diabetes. Fatigued at the end of a long work day with an hour-long commute, and overwhelmed by a sudden change in health status, John is inconsistent in his self-care. At John's next office visit for a follow-up examination and blood work, the physician talks to him again about the importance of diet and exercise, but he continues to have difficulty being compliant.
With SDM and SMS, the approach changes: Beyond giving John a diet printout or a brochure on how to manage diabetes, a board-certified case manager in the physician's office provides him with access to in-depth resources about diabetes and managing the disease over time. John now has evidence-based information at his fingertips to facilitate his decision making and also to inspire him to make good lifestyle choices around diet and exercise every day.
By becoming more informed, individuals also make empowered decisions about the treatment that makes the most sense for them. For example, when "Ann" was first diagnosed with early-stage breast cancer, she immediately told her doctor that she wanted a mastectomy to prevent the cancer from spreading or reoccurring. Fear, not information, was driving Ann's decision making. Once she was given access to credible, in-depth information about breast cancer and the risks associated with each stage, Ann opted for a less-aggressive course of treatment, including removal of the growth and radiation. A year later, she is cancer-free.
Case Managers Lead Transition to SDM and SMS
The transition to putting SDM and SMS in action follows a learning curve for both clinicians and their patients. The board-certified case manager is front and center in implementing these approaches in primary and specialty care settings, where decision making happens real time and not after the fact. To carry out these responsibilities most effectively, professional case managers may have to improve their communication skills, including using motivational interviewing techniques to identify the individual's goals and obstacles to achieving them (Tahan & Sminkey, 2012, pp. 164-165). Communication skill-building for case managers is also available through the Case Management Body of Knowledge (CMBOK), which emphasizes the importance of good communication to establish rapport with the individual, to reduce stress for all involved, and to pursue improved outcomes for individuals, providers, and the health care organizations (Commission for Case Manager Certification, 2012, p. 1). By embracing SDM and SMS as part of the case management process, professional case managers can make a measurable difference in the health care experiences and outcomes of individuals who are truly empowered and informed as they make decisions that work for them and their health goals.
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