In complex cases involving severe and catastrophic injuries and illnesses, care transitions present particular challenges and risks due to the long-term nature of care. Professional case management is essential to addressing these risks and challenges by facilitating communication across a transdisciplinary team and empowering individuals to improve their self-care (Campagna, Nelson, & Krsnak, 2019). Although every case manager can contribute meaningfully to improving care transitions, this column focuses on the role of field case managers who perform on-site case management as they handle workers' compensation cases involving severe and catastrophic workplace injuries.

Field case managers are not involved in hands-on care delivery (Baker, 2019). Rather, in their role as advocates for severely and catastrophically injured individuals, they are the "eyes and ears" that help observe and assess the individual's needs as care is provided along the continuum. Moreover, by being assigned to cases in the field, they are the "boots on the ground" as they collaborate and communicate with case management colleagues in a variety of care settings, such as those who work telephonically or are based in hospitals, rehabilitation facilities, long-term care, home health, and the community.

Although practice settings, roles and responsibilities, and professional disciplines vary, among professional case managers, the case management process is universal. According to the Code of Professional Conduct for Case Managers (Code), published by the Commission for Case Manager Certification (CCMC), professional case managers assess, plan, implement, coordinate, monitor, and evaluate the care plan and the options and services required to meet an individual's health needs (CCMC, 2015). Moreover, all case managers are joined by the common, overarching case management principle of advocacy. As the Code further states, "Board-certified case managers (CCMs) believe that case management is a means for improving client health, wellness and autonomy through advocacy, communication, education, identification of service resources, and service facilitation" (CCMC, 2015, p. 3). With catastrophic injury management, advocacy necessitates a whole-person view that extends beyond each episode of care. This is crucial as an individual moves through the health care continuum from acute care to subacute, rehabilitation, and long-term care or returning to home-a process that may take 12-18 months.

Serving Short-Term and Long-Term Goals

As field case managers, we collaborate with other case managers across the continuum who, by the nature of where they practice and the services they provide, are focused on shorter term goals. For example, a hospital-based case manager coordinates care to meet the individual's needs and goals while in acute care and to support a successful transition to the next care setting. During that phase of care, the field case manager is aligned with acute care case management while still taking the longer term view of further care, treatment, interventions, and care settings-in other words, what comes next in pursuit of the individual's long-term goals.

Although the clinical team may be most engaged with the support system/family at discharge to prepare them for the demands of ongoing care, the field case manager sees them from "day one," immediately after the occurrence of an injury. This puts the field case manager in the position of providing additional information and facilitating communication among all parties to help inform discharge planning. For example, instead of being discharged to a rehabilitation facility associated with the hospital, the individual and his or her family or support system want to explore other care choices. The field case manager who has direct interaction with the family/support system over a long period of time can meaningfully contribute to these discharge planning discussions.

Lack of a Support System Increases Complexity

When severe injuries intersect with psychosocial challenges, the complexity of the case increases. Workplace accidents may involve individuals who have few financial resources and/or who may not have a support system where they are living. Care coordination in these instances involves not only the clinical and rehabilitative aspects but also financial, psychosocial, spiritual, and other aspects of the whole person. Such was the case with "Ron," a 19-year-old recent immigrant who was working construction for a man initially identified as his uncle. A workplace accident resulted in an incomplete spinal cord injury that left Ron unable to walk without bracing and in a wheelchair for most of the day. When Ron was first taken to the hospital, his "uncle" signed consent forms so that Ron could undergo emergency surgery. After that, the "uncle" (who was later determined to be his employer and not a relative) was out of the picture.

I was assigned as Ron's field case manager by the workers' compensation insurer. When we first met, Ron's English was very limited, and we communicated through an interpreter. After Ron's surgery, he was transferred from the hospital to a rehabilitation facility where he spent about 12 weeks. The next transition would be back to the community with outpatient services, which presented a particular challenge in Ron's case because he did not have a place to live. Prior to his injury, he lived with multiple other "work friends" in a third-floor apartment with no elevator. This was a major impediment to a successful care transition. Without a supportive living environment, Ron was at risk of complications that could impair his health, safety, and well-being.

Through much coordination with the rehabilitation team and the case manager at an inpatient rehabilitation facility, as well as the social worker and the case manager at a potential residential setting, a temporary private assisted living home was identified for Ron. This temporary living arrangement was paid for by the workers' compensation insurance while he completed outpatient treatment related to his injury. With his living arrangement secured temporarily, my concern was to find a long-term solution for Ron, and I continued to work closely with a social worker to assist him in applying for other sources of residential funding. Ron's primary concern was how he could support himself and help provide for his mother and six siblings back in his country of origin. He was enrolled in a free English class at a community college and was hired by a local tool and parts business in a job he could perform from his wheelchair with limited retraining.

Managing Ron's case took more than 14 months, but for many years later, he would call me every Mother's Day and leave me a message in broken English, expressing his appreciation for everything that had been done on his behalf. While Ron did not use the word "advocacy," he understood the essence of this core case management value. His acknowledgement on Mother's Day conveyed to me that he felt his needs and goals as a whole person had been acknowledged and met. An entire care team across each level of his rehabilitation had coalesced around him and his needs. As his field case manager, I felt gratified that Ron could achieve the outcome he desired: to live independently and provide for his family.

Reflecting on Ron's case, I am reminded that throughout my more than 20 years in case management, including as a facility-based case manager, I have developed a real passion for field case management. In field case management, no two cases are alike; even if injuries are similar, other factors such as age, health status, and lifestyle become variables that influence the provision of care. Moreover, as a field case manager I have been privileged to work with case management colleagues from various disciplines, social workers, and clinicians across a number of facilities and care settings. At each juncture, I am the "guest" in that care setting who must show finesse and partnership to build relationships with other members of the care team. My job is to assist and collaborate with case managers and other professionals whose perspectives are shorter term than mine but our goal is the same: Together, we advocate for catastrophically and severely injured people to pursue their goals in the short and long terms.

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