Considering Case Management Practice From a Global Perspective

Case management is a collaborative process that occurs around the world. No matter where a case manager resides, our professional practice relies on uniform application of our Standards of Practice for Case Management (Case Management Society of America [CMSA], 2016). This article provides a snapshot of the global response to the COVID-19 pandemic, racism, bias, and the continuing global inequality in health care delivery and access. Specifically, this article creates a framework that will help the reader build awareness about our global community. I hope that this article will help case managers critically think about and reflect upon the importance of applying our ethics, advocacy, cultural competence, and resource management standards (CMSA, 2016, pp. 28–29) within a diverse global community. The foundation of our professional practice is the five fundamental ethical principles: beneficence, nonmaleficence, autonomy, justice, and fidelity (CMSA, 2016, p. 28). During these turbulent and crisis-driven times, we continue to be challenged to quickly adapt and retool our approaches to meeting the needs of the individuals and stakeholders we serve. Literature Review and Discussion To consider how we can effectively respond to numerous global issues, we need to change our lens of how we allow ourselves to see things. It is essential to recognize that the United States, or any other country for that matter, is not insulated within the global community. Our world is facing critical issues that require a collaborative response. Case management professionals have been part of a legacy that promotes reciprocal learning and application of evidence-based practice within our international network of colleagues. We must continue to learn from our worldwide neighbors and apply best practices. In addition, we need to understand that many of the following issues are interrelated. When working through high-stakes issues, it is critical to consider how we can implement a systems approach and change strategy that mitigates and ultimately prevents poor health outcomes, improves access to health care, and promotes continuity across our health care system. We need to establish cause and effect. Underlying this analysis is supply, demand, political will, bias, and the social determinants of health. Scarce and limited resources across our world further complicate our ability to develop a unified response. In this situation, our alternatives can be reduced and consequently affect our ability to make choices that satisfy the needs of the individuals and stakeholders we serve and care for. The COVID-19 Pandemic Is a Global Issue Historically, it is widely recognized that some type of pandemic would happen. For example, in 1952, the World Health Organization (WHO) initiated the Global Influenza Surveillance and Response System. During the last 10 years, the WHO has modified international health guidance to emphasize the importance of global health security (Zhang & Wood, 2018). There are varying global rates of COVID-19 infection and mortality based on governmental response and other social determinants of health (Kavanagh & Singh, 2020). International travel and tourism have been a well-established and growing practice that influences transmission rates (Blackman et al., 2019). Amidst COVID-19, we see how infectious disease can cause implicit and explicit bias. The ravages of the pandemic have caused significant unemployment and health insurance discontinuity. The pandemic has significantly affected children more due to a disruption in health coverage and parental employment (Tumin et al., 2019). Of significance is rising concern over declining childhood immunization rates and other preventive services (Peck, 2020). Medical isolation and social distancing further complicate our ability to communicate with those individuals we serve effectively. Face coverings reduce our ability to pick up on nonverbal communication. “Connecting with others normally helps individuals to regulate their emotions, cope with stress, and remain resilient” (Matias et al., 2020, P. 875). Our biases can significantly influence our ability to provide person-centered end-of-life care (Hunt et al., 2019). Mental Health Is a Global Issue The WHO has declared that the COVID-19 will disrupt mental health services worldwide (WHO, 2020). “Exposure to socioeconomic harsh conditions or poverty during childhood may have an irreversible negative impact on later physical and mental health” (Costa et al., 2020, P. 2). Research also demonstrates that mental health issues intensify and cluster within vulnerable populations living in isolation, uncertain times, and disruptive conditions (Canevelli et al., 2020; Patel et al., 2018; Satinsky et al., 2019). Racism and Bias Are Global Issues Without a doubt, racism has plagued our global community. “Racism is the belief that there are human groups with particular (usually physical) characteristics that make them superior or inferior to others” (United Nations, 2020). The most vulnerable individuals progressively are besieged by racism and bias (World Economic Forum, 2020). Researchers have identified implicit bias in global health care delivery for many decades (Maina et al., 2018). The seminal work by the Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care (2003) noted that “socially conditioned implicit prejudice may be manifested in healthcare providers' nonverbal behaviors reflecting anxiety (e.g., increased rate of blinking), aversion (e.g., reduced eye contact) or avoidance (e.g., more closed postures) when interacting with minority rather than White patients” (P. 162). Ogungbe et al. (2019) discuss how implicit bias can “multiply” based on an individual's observations. For example, an individual who is Black and homeless can increase unconscious bias more dramatically than an individual who is White and homeless. These “habits of the mind” can result in observed changes in clinical judgment and behavior (Burgess et al., 2017). Lack of a welcoming environment and limited psychosocial resources increase the risk of developing chronic diseases among African Americans (Sims et al., 2019). Homelessness Is a Global Issue In the United Kingdom, they call it “sleeping rough.” The Queen's Nursing Institute (2020) notes that homeless individuals are 50 times more likely to have hepatitis C, six times more likely to have heart disease, and nine times more likely to commit suicide. In Canada, more than 30% of the homeless shelter population is Indigenous People, and almost 3,000 Canadian veterans are homeless during the year (Canadian Observatory on Homelessness, 2016). Research by Marek et al. (2020) describes how gypsies experience implicit bias in health care. They noted how a clinician's tone and style of speech changed when caring for this vulnerable population. “These behaviors ... may be rooted in their family, their upbringing, and may also be due to the social and media influences they have been exposed to over their lifetimes” (Marek et al., 2020, P. 35). Joseph (2018) describes implicit bias as an “automated cue response,” whereas Narayan (2019) states that it is “part of the human condition.” Advocates estimate that there are more than 567,000 individuals who are homeless in the United States (National Alliance to End Homelessness, 2020). Research in the United States noted that many homeless individuals felt that nurses “judged and shamed them” for their irresponsible behavior (Astroth et al., 2018). Historically, we have treated poverty, those “visibly poor,” and homelessness as a crime (Rankin, 2019). Case managers need to recognize that homelessness is a complex and individualized issue resulting from a myriad of systemic failures (Fraser et al., 2019). Food Insecurity Is a Global Issue “Our world is on the verge of a hunger pandemic” (United Nations News, 2020). Our global pandemic, coupled with hunger, is the fuel that will escalate our world's insecurity and increase tension and hostility. Research demonstrates a direct connection between food insecurity and poor health, and between social and educational outcomes, leading to higher health care expenditures (Berkowitz et al., 2018; Graham et al., 2018; Peltz & Garg, 2019). Police Brutality and Military Brutality Are Global Issues In 2019, police in Rio de Janeiro, Brazil, killed 1,810 individuals (Amnesty International, 2020). In 2020, Nigerians are rioting in protest of police brutality. “Populations made up of the marginalized or the poor, ethnic or racial minorities, immigrants, or anti-government protesters may find themselves dismissed, criminalized, or subjected to violence” (McSherry, 2019). Again, we face the common denominator—vulnerable populations. Application Within Professional Case Management Practice Experience is not what happens to me; it is what I do with what happens to me. (Aldous Huxley, 1932) Huxley (1932) reminds us of the importance of learning from our experiences. Our knowledge, lived experiences, and memory have a powerful ability to influence our growth mindset. Our lived experience, in turn, motivates and empowers us to “persist when encountering difficulties” (Yeager et al., 2019). Think back to the roots of nursing. The image of a nurse in the 19th century was scandalous. “Chronicles of the social ‘evils' of the 18th century characterized nurses as old, ugly, immoral, and cruel women who cared little for their patients and only for what little money they received or stole” (International Museum of Science, n.d.). In the early 1900s, we worked hard to change our public image from vocational work to an “ethic of social good” and professionalism (Hallam, 2002). Case management professionals need to be aware that we can easily “transmit” implicit bias through medical record documentation (Goddu et al., 2018). A review of medical record coding noted that the severity of similar illness increased on the basis of age, gender, and ability (Torres et al., 2019). A Canadian study noted how weight bias resulted in derogatory perspectives (Alberga et al., 2019). Stigmatizing words can be compelling in creating and reinforcing an environment of disparate care. “Holistic and individualized healthcare recognizes human rights to health including individual autonomy and safety, such as having basic rights and freedom to access quality healthcare, and that individuals should be treated fairly, equally, and impartially” (Lundin et al., 2018, P. 2). A great way to understand your own implicit bias is to participate in an implicit association test or other assessment activity. Project Implicit (n.d.; https://implicit.harvard.edu/implicit) and The MindTrails Project (n.d.;https://mindtrails.virginia.edu) are great resources in exploring how your subconscious and mindfulness can affect your practice. You can complete anonymously, and this input adds to the body of research. During this pandemic, health care organizations around the globe have curtailed elective procedures and routine preventive health services. Historically, we have seen how economic distress within a country has significantly affected at-risk and vulnerable populations (Towne, 2017). Organizations have relied on telehealth to help bridge some access and care gaps, but we must remember that vulnerable populations may not have access to telephonic or web-based resources. As health care advocates, we need to build awareness of how we can reduce bias and prejudice. Effective and individualized communication is the foundation of building trusting relationships, improving our interactions with marginalized individuals, and building social justice (FitzGerald & Hurst, 2017). Although group training does build some awareness, it is crucial to recognize that our accountability is critical in diminishing institutionalized inequities (Pritlove et al., 2019). One way to reduce implicit bias is to rekindle our passion for supporting our ultimate goal of providing exceptional care to the individuals we serve. Another way is to improve our reflective practice by taking time to pause and evaluating how our biases and interactions can affect vulnerable populations (Schwartz et al., 2020). Reading about vulnerable and disenfranchised people's life experiences is a great way to change your perspective, safely move out of your comfort zone, and evaluate your behavior and response from a different lens. Dovidio and Fiske (2012) note the importance of increasing diversity of individuals working within our health care delivery system to support the delivery of patient-centric care. We also must continue to change our mindset and approaches from medical care to holistic care (Kuo et al., 2018). More importantly, we need to self-reflect and consider how our biases may affect how we care for and treat others. Understanding that our subconscious thinking influences our actions is key to changing our mental models of equitable care delivery. When we consider health care disparities and the delivery of health care services to vulnerable populations, we need to consider the impact of social determinants of health and social isolation (Sinvani, 2020). Collaborative practice and building trusting relationships with patients and other stakeholders are ways to consider different perspectives that assist our community in improving access to care, health promotion, and health innovation. Truly understanding our community members' unique needs will help us create innovative approaches that respond to stakeholder needs. Finally, we need to be part of the global solution by finding impactful interventions and developing an evidence-based practice that positively affects vulnerable populations' lives. As professional case managers, we have an ethical and professional responsibility to raise awareness through advocacy and education. We must change the narrative and move toward a more inclusive society. Furthermore, we need to take care of ourselves in order to build resilience.

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