John" was a spinal cord injury patient, receiving treatment in a rehabilitation unit following an accident in the workplace. He was progressing well and prided himself on his independence, such as being able to wheel himself to physical therapy and around the facility. During an on-site evaluation to monitor John's progress, the field case manager assigned to handle his workers' compensation case noticed that the wheelchair John used did not have a cushion. In addition, when the case manager was in his room as the nurse bathed John, she observed a reddened area on his buttocks.

Field case managers receive information largely from written reports by physicians and staff. During on-site visits, these case managers use their observation skills, making assessments with only their eyes, ears, and clinical knowledge. In John's case, the record did not mention any redness or concern about the potential risk of a pressure area. In her observation, the field case manager saw no evidence of a wound, which would have required immediate treatment-only a reddened area. In addition, the staff had observed John doing periodic "pressure release," raising himself out of the wheelchair using his hands and arms. The need for a cushion, therefore, was likely an oversight. The redness was still a concern; the field case manager brought it to the attention of the nurse, while also informing the staff of the importance of obtaining a cushion for John's chair.

John resisted the idea of a cushion at first. "I don't feel it-I'm fine," he said repeatedly. The case manager explained that, without a cushion, John was at risk of getting a pressure wound; if that were to occur, he would be in bed receiving treatment and not mobile in his chair. Finally, John agreed. It took about 10 days from the time the field case manager requested the cushion to when it was delivered. In between, the case manager was persistent but respectful when inquiring about the cushion, using questions such as: "I haven't seen an order for that cushion yet. Is it in process?" and "How are we doing on that cushion?" When delivery was finally made, the field case manager emphasized to John that he must use the cushion every time he was in his chair. The field case manager collaborated with the nursing staff, who agreed that the cushion should be in place before John was put into his chair every day.

By advocating for John, the field case manager was able to mitigate the risk of a pressure wound and preserve his mobility and sense of independence. But this could be done only with the cooperation of others. With each interaction, the field case manager supported collaboration among the staff to reach their common goals.

Communication and Collaboration

The Code of Professional Conduct for Case Managers states that the case management process "assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet an individual's health needs" (Rev. 2015, p. 4). This applies to case management in every health or human services setting and is the cornerstone of practice for case managers from various disciplines, including nursing, social work, and rehabilitation.

Given the long-term nature of severe and catastrophic cases, which can require 18-24 months of field case management, all parties involved in the individual's care must be embraced as part of the team. As the Code also notes, the case management process is "professional and collaborative" (2015, p. 4). Some state workers' compensation regulations only allow field case managers to provide intervention and coordination, thus prohibiting them from providing direct care.

This puts the responsibility on the field case manager to communicate clearly with the individual and his or her family or support system and to provide information and education that support informed decision making. In addition, the field case manager must communicate and interact with every member of the care team in a way that is cooperative and nonadversarial.

There may be times when field case managers encounter discrepancies between what they read in the medical record and what they see; for example, the record states that a patient is able to empty his or her bladder on his or her own, but at the bedside, the field case manager observes a catheter bag. It might be an instance of an error in the record or perhaps a change in the person's health status that was not yet recorded. Such discrepancies need to be brought up to the staff in a way that seeks clarification by asking questions but does not accuse or cause conflict. While on-site, the field case manager may also participate in team meetings, at which observations can be shared; for example, if the care team notes that a wound is not healing as expected, the field case manager who observed a nonsterile dressing change can share that information. The intention is not to be punitive but to advocate for the best care for the patient.

Beyond the Episodes of Care

Another aspect of field case management is looking beyond acute care and rehabilitation to the day when the person can return home or transition to another place of residence. Although workers' compensation regulations differ from state to state, when individuals are severely injured and have permanent disabilities, they are likely to receive approval and funding for home modifications. Often, the result is a significant improvement in life quality, allowing for greater mobility and independence.

"Fred" became a paraplegic after an injury that resulted in permanent disabilities. After a long treatment (Fred spent 6 months in intensive care and then 6 months in rehabilitation), the family wanted him back home. The extra-wide wheelchair that Fred used, however, could not fit through the front door of the house where he and his wife lived.

The field case manager had already intervened for Fred earlier in his treatment: While in the acute trauma hospital, the staff observed that Fred was depressed and suggested that he be sent home before receiving rehabilitation, thinking that would be good for his mental health. The field case manager, surmising what would likely happen if Fred were discharged without rehabilitation, raised the question: "He's never been put in a wheelchair before. How can his family care for him if he hasn't had rehabilitation?" Fred was then transferred from the hospital to a rehabilitation facility to support his eventual discharge.

At home, preparations had to be made. The field case manager facilitated discussions with a contractor and worked with a physical therapist who specialized in home modifications. Recommendations were presented to the workers' compensation insurer, which approved expenditures for modifications such as enlarging the front door, knocking out a wall to convert the bedroom into a larger space, and installing a roll-in shower in the bathroom.

Once he was home, Fred transitioned to a power wheelchair, which he would "drive" six to seven miles a day around his property; as a result, there was an ongoing need for repairs to the chair from an out-of-state company. Fred lost his independence during those times when he was unable to use the chair for mobility. A family friend, who was a mechanic, was able to modify a small, high-performance utility vehicle with a seat that swung out. The field case manager educated the responsible party and was able to obtain funding for the parts for the mechanical conversion. This allowed Fred's wife to push him down the ramp from the house and use a lift to get Fred into the seat. He was then mobile for the rest of the day.

In summary, field case managers serve a unique advocacy role in the care and rehabilitation of individuals who have been severely and even catastrophically injured. In their on-site roles, they must heighten their observation as they assess progress and identify needs. Although communication is central to case management in any setting, in field case management it is intensified to ensure that information (including emerging risks, changes in condition, and the person's needs) is shared with the entire team, as well as from physician to physician. Such communication is not only about content but also about context. Being tactful, the field case manager can raise questions and ensure that information is shared respectfully, but thoroughly, and in a way that no one feels reproached. This approach supports an interdisciplinary team that collaborates on behalf of the individual and the pursuit of his or her health goals.

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