Do you ever wonder "Why did I choose to be a case manager? Did I just stumble into the role? Did I think I could bring value and a sense of comfort to those I serve? Was it personal? Was it convenient? Did those around me question, 'Why was I giving up my professional healthcare role?'" Did that give you pause, as it did me?

As we head into a new year and take the time to reflect on our role as case managers, I encourage all of us to take time to ponder over "Why did I choose this role, and is it right for me and those I serve?"

For me, the answer is "Yes!!" I am in the right place and at the right time. This does not mean that I do not experience frustration, just like everyone else. But that one client, one patient, one human being at a time is hopefully more comfortable, more confident in his or her understanding of his or her condition, and feels more supported because of the role I bring to the process.

Looking back on 2008, my client load was varied and included international patients coming to the United States for high-acuity, complex services, as well as clients needing coordination of end-of-life care. Although the care planning, objectives, and outcomes were different, the overall goal remained the same: support, advocacy, and respect of patient choice.

Which brings me back to my first question-Do you ever wonder?

* How did healthcare get so complex?

* Where is the "road map" for getting through the system?

* Is there anything we can do as case managers to simplify the process?

I know that we all want to be part of the "solution" to improve healthcare, but we have to recognize that we are also part of the problem. How often do we see more than one case manager on a case? How often do we not promote or enhance improved communication and collaboration? We, as case mangers, recognize our contribution to the problems; therefore, it is up to us to be part of the solution.

I continue to believe that case managers have a significant role to play and it continues to be most valuable, one patient at a time. Recently, I cared for a 92-year-old gentleman with an 89-year-old second wife and children from each marriage. He had just been told that he had recurrent colon cancer and that the prognosis was limited to 4-6 weeks. He told me on my initial visit with him, and every subsequent visit, that he had a good life, did not want to die in a hospital, and wanted no treatment that would prolong the dying process. His children and wife understood and made plans to be at his side as questions were posed and answered simply and honestly. Care was implemented to support him, and his choices were respected.

This all sounds relatively simple-not easy for his loved ones, but simple. However, here is where I believe that the system has become too complex. There were three case managers involved. The agencies involved did not have a process in place for communication; rather, they relied on the client or family to communicate with them. The physician, albeit loved and admired by the patient and his family, again was not initiating communication, but responding when contacted. This left the family in a position of reacting and wondering:

* When and what do I tell the doctor?

* What can I expect to see as changes?

* What should I expect to see as Dad slips away?

* Whom can I share my feelings with? He is my Dad[horizontal ellipsis]"they" need to know him as a person.

* Whom do I contact, and when, if I have a question?

As the case manager hired by his children, I took the time to sit with them and their Dad and got a sense of who he was throughout his life and who he is today. I answered their questions and supported their decision making. They knew I was their advocate, so that when things got complicated, it was one telephone call and they would have someone to help resolve issues. And when the call came very early on a Sunday morning, they knew that they had support and that they had followed their father's wishes.

I wonder about a lot of things, but there is one thing I have no doubt about. We as case managers always do our best work when have one patient at a time. We have the heart to listen, support, and advocate for our patients. We make a difference when we follow our heart to assist our patients and the healthcare team in providing opportunities and choice. I have never written my own care plan and hope I never will. I just pray that I am blessed with a case manager who manages from the heart and does not wonder why he or she became a case manager, but knows that he or she could not do anything else.

The intent of this column is meant to speak to the heart of case management: our joys, our struggles, and our lessons learned. Please send your thoughts and ideas to us so we may include them in future articles: Peter Moran at [email protected] and Mindy Owen at [email protected].