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Of Mice and Men


The motto of the Case Manager is:  Plan for everything, but expect the unexpected!  An idiom from the famous novel Of Mice and Men says it best, "The best laid plans of mice and men often go awry." As healthcare and Case Management becomes more evidence based, it becomes easier to guide WC providers to evaluate progress and base orders on objective findings.  Use of references such as the Official Disability Guides ensure evidence based practice.  So what can go wrong?  

A few years ago we began working with a local provider who sought out WC business.  He let Case Managers help him learn to base orders on objective findings.  He'd done well and seemed to developed a predictable formula that effectively addressed related symptoms and never prolonged the treatment plan unnecessarily.  Many CM's began to flock to him.

Then a JMS Case Manager brought him a patient that voiced a desire to get disability; on the first visit.  He treated her according to "evidence" and treatment guidelines for her diagnosis.  She progressed and he prepared her for return to full duty (at the next visit).  When the final visit came he explained that he based his full duty order on lack of findings (not even a muscle spasm).  He was kind and encouraging to her.  She burst into tears!

She bawled and squalled in the exam room.  When she finally calmed down enough to talk she said (between sobs) "I just can't work."  Our very adept and now experienced provider rescinded his order and gave her eight more weeks off.  (Insert sounds of case manager wailing here) During that time she quit exercise because she said she simply was not the kind of person who exercises.  Her husband said he'd be happy if she would just walk the dog.  He did all the cooking, child care and working.

So we started out with a solid plan that was evidence based and effective.  We were organized and had a reasonable, even generous treatment timeframe.  We ended up with confusion and delay caused by paradigm shift: Physician directed plan, changed to "crying patient" directed plan.  

We finally got an FCE, and despite more tears - MMI.  We avoided long term treatments such as pain management and the employer returned her to work.  For a seasoned CM that was a small victory.  We gave that MD a box of Kleenex for Christmas...he got the message.

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