Case Management in the Pediatric Setting
Caring for patients in a pediatric setting looks different than serving the adult or geriatric populations. The role of the family often is more prominent in pediatrics, the interventions may be distinct, and case managers may need to engage in self-care.
After working with geriatric patients, Matthew Combes, LCSW, LSCSW, CMAC, ACM-SW, director of integrated care for Children’s Mercy Pediatric Care Network in Kansas City, noticed right away the role of the family was different in pediatrics.
“When working with pediatric patients, you’re actually working with their entire family,” Combes notes. “In geriatrics, you’d work with the family, and especially adults, who were caring for an elderly adult. But a lot of times, the geriatric patient was still decisional and able to call the shots while the family supported them.”
When working with adults who are making their own decisions, it is important to understand the role of self-determination, even when the adult is making “poor” choices, Combes explains. Although this can be hard for a case manager and the medical team, it is a reality of an adult population. But in pediatrics the patient/child is not independently making nearly any decision.
“Instead, sometimes we have a parent who is making not-so-good choices for the patient, and it can be difficult to respect the parent’s wishes for the health of their child,” Combes says. “When working with pediatrics, you are working with a vulnerable population who are predominately not making their own decisions. It is important to recognize the parent/caretaker as the “expert” in their own child.”
Combes acknowledges this can lead the care manager and the medical team into a series of ethical questions: “Do these choices fall into parental rights for determination of what is best for their child? Are these ‘poor’ choices negatively impacting the child to the point of harm that constitutes abuse/neglect?”
Pediatric case managers also should be aware of the need to constantly engage in “code-switching.”
“When we switch from talking with kids to turning and discussing with parents, the talk looks different,” Combes says. “In case management, we have to meet the patient where they’re at, and it takes certain skills to work in a pediatric setting where the patients might be very young and don’t understand. Still being able to switch from working with that kiddo and that adult are skills that the case manager needs to have.”
Often, interventions for pediatric patients are “broader and more concentrated on the family needs, such as food, shelter, etc.,” Combes says. Therefore, social workers might play an even greater role with this population as the needs can quickly go beyond medical to social. For that reason, Combes is an advocate for integrating the case management and social work roles as much as possible.
“My current population is largely Medicaid, so they have medical needs for which nursing brings knowledge. But with the Medicaid population also comes a lot of social, behavioral, and resource support needs that a social worker brings to table,” he explained. “I can’t silo out needs. I need nursing and case management to work closely with the social worker. It helps when programs look at case management as a team coming to the family together — never as a competition, but as a collaboration.”
While every hospital unit carries certain difficulties and challenges, case managers in the pediatric unit often see and experience devastating circumstances out of their control.
Combes, who previously worked in foster care, said it is important to compartmentalize and set boundaries when working in these situations, for the sake of the case manager’s own mental and emotional health. Seeking additional education on and understanding abuse and neglect can provide an additional framework.
“Recognizing and understanding abuse and neglect is very helpful within the pediatric population, and case managers should also strive to understand the laws around it,” Combes explains. “Also, we see lots of traumas and neglect, and yet still have to work with that family in that situation. It’s important to keep in mind that we need to always respect the individual, remembering that past experiences are not always a defining factor in who someone is. There are opportunities for rehabilitation and supporting the family, and no one is beyond improvement. Some just need lots of guidance.”
When these difficult situations are at risk of taking a toll on the case manager’s mental or emotional health, it is a reminder to set clearer boundaries and ensure a mentor or direct supervisor is in place to work alongside the case manager.
“It’s easy, especially in the pediatric setting, to take things home,” Combes says. “Instead, we need to focus on work at work, and then at home focus on self-care, removing yourself from what you’ve experienced and the trauma that you’ve seen. It gets easier over time to cope this way, especially when the case management department has ways for the case manager to talk through handling complex cases. We need good support systems and strong boundaries.”
With the right plan in place, the pediatric setting can be an excellent arena for case managers to serve patients and families who are enduring difficulties. Combes says this is made even more rewarding when the case manager works well with community-based partners and has a leader who walks alongside the case management team. He also shares a bit of good advice that can make the whole experience better for everyone.
“To the extent that you can, make it a fun environment for kids,” Combes suggests. “When case managers meet with families experiencing the worst part of life, it’s an opportunity to make whatever they’re going through as pleasant as possible. That’s when those case management skills of empathy and understanding can help guide them on the path that they choose, connected with all the resources they need, now and in the long term.”
Caring for patients in a pediatric setting looks different than serving the adult or geriatric populations. The role of the family often is more prominent in pediatrics, the interventions may be distinct, and case managers may need to engage in self-care.Subscribe Now for Access
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