Nursing case Management

Nursing Case Management

Case management contrast: Treatment refusal of a thirty-year-old male with AIDS

Innovations in drug treatment have transformed AIDS into a chronic illness, not the death sentence it once was, for many sufferers. Today, antiretroviral drugs are prescribed for most AIDS patients. However, because of the difficulties of the complex and finely calibrated drug treatment regime and the high frequency of debilitating side effects as a result of these drugs, treatment compliance can prove challenging. In the case of a thirty-year-old male with AIDS who refuses to adhere to his treatment regime, the AIDS Institute offers two models of case management as a way of dealing with the problem: supportive case management and comprehensive case management. Both approaches are multi-step processes and address the medical, psychological, and social needs of the patient and his support system, but the latter is far more intensive, and likely more appropriate for this particular patient than the former.

The supportive case management model is focused on the immediate needs of the person living with HIV / AIDS, such as the lack of medical treatment and self-care, as opposed to long-standing issues, as to why the man is not taking his medication. "Supportive case management is suitable for persons with discrete needs that can be addressed in the short-term" (Case management definitions, 2009, Department of Health). The individual's reasons for not taking his medication would be identified -- such as a lack of funds or comprehension of the necessity of his treatment. He would then be referred to appropriate agency services to address this immediate need. For example, if the man did not adhere to the drug regime because it was too difficult to take the drugs at the right time during his employment, he might speak to a legal advocacy group for disabled people, who could negotiate with his place of work to see if he could be accommodated. If he needed financial assistance for the costly drugs, he would be referred to the social service agencies that could help him. A nurse case manager might be able to go over his treatment plan with him for clarity, or the treatment plan could be simplified and fine-tuned, if possible.

However, a failure to comply with a life-saving but difficult drug treatment is likely to be due to multifactoral problems, not a single problem. That is why comprehensive case management, which is intended to serve the needs of patients who are willing to agree to a longer and more intrusive levels of supervision, service and intervention, is likely to be more appropriate for this patient. The lack of willingness of this client to engage in positive self-care may be due to a combination of economic, social, and psychological factors. "Clients engaged in comprehensive case management will receive frequent contact, follow-up provided in the community and, in some programs, home visitation. Comprehensive case management services may be provided by a single case manager or by a case management team" (Case management definitions, 2009, Department of Health).

For example, the individual may not feel he is truly 'sick' because he does not feel bad, may not wish to suffer the side effects of the drugs, and not fully how to understand to take them properly. Psychological counseling, the assistance of a nurse, even a meal provision service for the sick and the disabled all might be necessary to ensure that the man was compliant. The goal of comprehensive case management is to provide interventionist services over the long-term, and AIDS is a long-term, chronic illness, even (or especially) when treated with antiretroviral drugs. In the case of a comprehensive case management intervention, the individual's immediate needs are first met (for example, the cost of the drugs or problems with coordinating medical treatment with employment). But then provisions are made to integrate social support services into the individual's life, such as home visits by a nurse, free home-delivered meals, or financial assistance.

For example, the patient might be contacted by a nursing facility to arrange for home visits to check on the individual's medical status. or, he could receive psychological as well as physical healthcare services on a regular basis. If the depression or mental issues are the obstacle regarding taking his medications, he may be connected with counseling services or a support group specifically designed to help AIDS patients cope with their illness. Long-standing social support is more likely to act as an additional motivator to be treatment-compliant than a few, brief sessions. If finances are an issue and cannot be resolved in the short-term with the patient's insurance company, "services may be supported by grant funds or Medicaid reimbursement" (Case management definitions, 2009, Department of Health).