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Issues in Pediatric Case Management
By Rhonda Cofield, MSW, LCSW
Common management and supervisory issues in health care can be found across different settings, but may find unique expression in some practice
settings or population-specific environment. Decision-making, child abuse and maintaining professional boundaries are issues that present unique
challenges in the field of pediatrics.
Case managers who choose to work in pediatrics often do so because they
love children. While nurse case managers may have provided bedside care
before entering the field of case management, they may not have pediatric-
specific experience. Likewise, social work case managers may or may not have
been experienced in pediatrics prior to working in the setting. Both
professions are trained about the developmental needs of the children they
serve and the bio-psycho-social factors that need to be considered when
working with children. However, there is often less professional training
regarding issues that affect working with children and how to resolve
children’s medical and social needs. It is the responsibility of management to
provide the in-service and other supplemental training opportunities that will
heighten staff members’ awareness of these issues and assure they develop
the necessary professional skills.
DECISION-MAKING IN A PEDIATRIC SETTING: THE ISSUES
The complex dynamics of health care decision-making are not necessarily
unique to pediatrics. Certainly, an adult’s competency to make informed
decisions is a focus in adult health care. The difference in pediatrics is that
patients generally have little or no input into the decision-making process
concerning their own health care. Children are brought to the health care system
by parents or guardians because of an illness, whether they want to be treated or
not. The parents or guardians are inevitably the ultimate decision makers.
There are a variety of common circumstances that create additional
complexity in the decision-making process. For instance, a chronically ill
adolescent who is knowledgeable about his condition may disagree with his
parents’ decision. Or, a terminally ill cancer patient may not want to continue
with chemotherapy, preferring palliative care, while his parents want to
continue treatment at all costs.
Blended or non-traditional families complicate decision-making as well.
Divorced parents may have shared custody that includes shared health care
decisions. There may be many informal decision-makers in an extended family
or kinship group, each of whom has influence on the parents’ decisions.
There may be legal restrictions concerning the decisions made on behalf of
a child. If the child protective services department is involved, the parents may
be able to make decisions about certain aspects of health care and not others.
A foster parent may be able to make some care decisions and not others. An
ironic twist is the case of very young adolescent mothers who are too young to
make decisions about their own health care but are the decision-makers for
their own infants. Therefore, a pediatric case manager can not focus on the
typical decision-maker but instead, must clearly define who has legal rights to
make the decisions and they must inform the health care team accordingly.
There are also legal boundaries that prevent parents from making health
care decisions that endanger their children. For example, a family that refuses
to agree to a blood transfusion because of religious beliefs may be endangering
that child’s life. Hospitals must have policies in place to address the procedural
aspects of resolving cases such as this.
DECISION-MAKING IN A PEDIATRIC SETTING: THE STRATEGIES
Knowledge of family dynamics and family intervention are key to
addressing these issues. While the parents or guardians will be the final
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decision-makers, as advocates for the patient, case managers must influence
the health care team and the family to involve the child in making decisions at
the appropriate developmental level whenever feasible. It is important to know
the child’s feelings about the treatments being received and to provide input
when appropriate. In many cases this will increase the child’s willingness to
participate and commit to the plan of care.
There should be a mechanism in place to determine who is legally able to
make health care decisions for the child and to clarify that information for the
rest of the health care team. If there are informal decision-makers in the family
or kinship groups, they should be identified early in the care process and
engaged in the decision-making process so that their influence is not
disruptive at a later time. If the child is in the legal custody of a child welfare or
child protective services department, the case manager must have a clear
process to determine the legal decision-making roles of the state agency and of
the parents and communicate this to the health care team.
Conflict and potential tension with decision-makers can arise as a result of
visits from non-decision-making family members (who are nevertheless vested
in the child’s well-being), particularly if there is ill-will between ex-spouses,
step-parents and ‘significant others.’ The case manager must have clear
direction in terms of visitation policies in order to appropriately deal with
conflicts as they arise.
If parents or guardians refuse treatment for their child, the hospital should
have clear policies and procedures in place to ensure the appropriate
treatment is started without life-threatening delay. Hospital policies and
procedures should delineate the steps to initiate treatment and who will be
involved. Risk management and the hospital’s legal counsel will likely be
involved. Direction should also be clear regarding guardianship of the child for
treatment purposes – for instance, the hospital might assume guardianship or
automatically report the situation to Child Protective Services.
SUSPECTED CHILD ABUSE OR NEGLECT: THE ISSUES
Suspected child abuse or neglect can run the gamut from medical non-
compliance—to sexual molestation—to severe trauma or death. Health care
team members often have strong, judgmental reactions to the families of
children who are suspected to have been abused or neglected. The reaction
will be particularly pronounced in the cases of long-term, conscious abuse or
when the child is very young.
It is imperative to recognize that the responsibility of the health care team is to
report suspected incidents, not to identify the perpetrator. Investigation, arrest and
the prosecution of perpetrators are the roles of other professionals. Caregivers must
guard against drawing their own conclusions regarding the guilt or innocence
of family members. When a caregiver is distracted with the determination of
innocence or guilt, it can lead to inappropriate behavior towards the family, who
is still responsible for making decisions until the authorities deem otherwise.
SUSPECTED CHILD ABUSE OR NEGLECT: THE STRATEGIES
Knowing the legal definition and requirements for reporting suspected
child abuse and neglect is paramount to appropriate case management. The
hospital or department must have clear policies and procedures in place to
govern all staff members’ responsibilities in suspected cases. These should
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include information about the reporting process, guidance with respect to
the documentation needs for the medical record and accessibility of the
medical information to the investigators. Frequent discussions and in-
service training concerning the roles and responsibilities of the various
health care team members involved in the reporting and follow-up actions
are necessary.
Staff members should be educated about the dynamics of family violence,
as well as how to identify their own reactions to child abuse. It is critical in
these cases to have a mechanism in place for staff members to deal with those
feelings, such as debriefing with a supervisor. In this way, case managers will
be important role models for other health care providers to treat these families
in a professional manner, despite their own feelings or suspicions.
PROFESSIONAL BOUNDARIES: THE ISSUES
Difficulty maintaining appropriate professional boundaries is a multi-
faceted problem in pediatrics and perhaps less obvious than in the adult
setting. Children have strong emotional appeal and when a child is ill, the
appeal is magnified. Common problems include:
• Over-identifying with the patient who is a similar age to his or her own child.
• Becoming critical of the parents’ parenting style – feeling that they know
better than the parent what is best for the child.
• Being “adopted” by the health care team when the family may not be able to
visit regularly -- buying special toys or clothes for the child, for example.
On some occasions, financial hardships or other circumstances create a
strong sympathy for the family and caregivers do not maintain appropriate
professional boundaries with the adult family members. They may become too
friendly with the parent(s): inviting a parent out to dinner or to their home or,
offering to take the family laundry home. There have even been examples of
staff members who date a child’s parent or enter into an intimate relationship
with the parent while the child is in their care. Although the child is a patient,
these behaviors with adult family members are always violations of
professional boundaries.
Supervision in Case Management (continued from page 5)
regardless of what initials follow their name. Content experts within or
outside the department are resources for information when needed. A
supervisor with a social work degree who needs technical information about
nursing can always obtain that information; the same is true for a nurse who
needs social work information.
IDEAS FOR STARTING A CLINICAL SUPERVISION PROGRAM
Admittedly, for case management departments which do not already have
clinical supervision programs, a request for additional supervisory FTEs to
initiate such a program can be difficult to support. It is important to educate
administrators on the value of a clinical supervision program, particularly in a
health care setting. One way to demonstrate that the investment reaps a
reward might be to pilot a clinical supervisor with some of the staff and
compare the outcomes that occur with those from the rest of the staff.
Key indicators would be patient care results, length of stay and satisfaction
measures from the department staff, unit staffs, and others on the health
care team, such as physicians.
At Spectrum Health, there is no question that time spent with clinical
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C A S E M A N A G E M E N T
When professional boundaries are crossed, other families usually note the
disparity and wonder why they do not merit the same special attention. When
a caregiver becomes a friend, the balance of authority shifts and the ability to
address care issues is inhibited.
PROFESSIONAL BOUNDARIES: THE STRATEGIES
Education regarding the purpose of maintaining professional boundaries is
critical. Inappropriate boundaries will always have an effect on the care of the
child. The difference between a professional relationship and the relationship
of a friend can be clearly articulated. In fact, most disciplines have a clear Code
of Ethics concerning the expected behavior that defines a professional
relationship. The hospital or department should have a clear policy that
defines these expectations and parameters for professional boundaries.
Because crossing professional boundary lines can happen subtly, it is
helpful to have discussions and frequent in-service training about the various
manifestations of non-professional behavior; case examples – real or
fictional—can be good illustrations of the subtleties. Individual instances of
violation should be addressed promptly by discussing behavior and helping
staff members return to a more professional stance. There should never be
hesitancy to remove a staff member from a child or family case assignment
where violations are suspected or to take immediate corrective action.
CONCLUSION
Decision-making, child abuse and professional boundaries are issues
that cross all professions in pediatrics. Case managers need to be able to
recognize how these issues affect their own practice. And, as facilitators of
the care team, they need to be able to recognize these issues when they
occur with other members of the team, and have the tools to address them
swiftly and constructively.
Rhonda Cofield, LCSW is the Director of Case Management at All Children’s
Hospital in St. Petersburg, Florida. She has over 30 years of progressive experience
in health care with over 15 years in pediatrics hospitals in Indianapolis and St.
Petersburg. She received an MSW from the Indiana University School of Social Work.
supervision pays off, creating a win-win-win situation. Care Management
employees are assisted to reach their highest potential; patients and families
benefit from improved care; and the health care system is enabled to provide
more efficient and cost-effective services.
Taffie Dollaway, RN, BAH, attended Muskegon (Mich.) Community College,
and earned her bachelor’s in allied health at Baker College, Muskegon. With
19 years of health care experience, she is presently a clinical supervisor in the
Care Management Department of Spectrum Health System, Grand Rapids, Mich.
Nan Hunt, MSW, CSW, has been in health care for 25 years, the past 20 at
Spectrum Health. She is clinical manager of the Care Management Department.
Her BS degree in education is from Central Michigan University, her MSW in
social treatment from Western Michigan University.
Susan Henning, MSW, ACSW, is a clinical supervisor in Spectrum Health’s Care
Management Department. She has 26 years’ experience in social work, the past
16 in medical social work at Spectrum Health. She received a BSW degree from
Central Michigan University and an MSW from the University of Michigan.