BY DR. COLLEEN MORLEY-GRABOWSKI, DNP, RN, CCM, CMAC, CMCN, CMGT BC, ACM-RN, IQCI, FCM, FAACM
As we continue to evolve in our role as case managers, the themes in this edition of CMSA Today touch upon some of the most profound and meaningful aspects of our practice: geriatric care, end-of-life planning, and hospice support. These themes are both timely and essential as we see the demographic shift of a growing aging population and face the unique challenges this presents in healthcare. Navigating the complexities of elder care requires not only clinical knowledge and organizational expertise but also a deep understanding of compassion, dignity and advocacy.
The Complexities of Aging and the Case Manager’s Role
Aging is a universal process, yet its experience is deeply personal. Our role as case managers is to guide individuals and their families through this journey, ensuring their physical, emotional and spiritual needs are addressed. Articles in this edition remind us of the tools and strategies available to support appropriate care planning and enrollment in programs like hospice or palliative care. The inclusion of topics such as frailty screening and connections to PACE programs highlights our responsibility to advocate for solutions that preserve quality of life and promote independence for seniors as long as possible.
Frailty screening is increasingly recognized as a critical tool in geriatric care and is now integrated into CMS (Centers for Medicare & Medicaid Services) guidelines. Frailty assessments help identify older adults at higher risk for poor outcomes, such as falls, hospitalization, and functional decline. CMS requires frailty screenings as part of certain care programs, particularly for dual-eligible beneficiaries and those enrolled in specific Medicare Advantage plans. These screenings are vital for developing individualized care plans that address physical, emotional and social needs while aligning with the patient’s goals of care. Case managers play a central role in implementing these screenings, interpreting the results and connecting patients to appropriate resources, including PACE programs (Programs of All-Inclusive Care for the Elderly), which offer comprehensive services to seniors to maintain independence and improve quality of life.
The article on AI alerts assisting with more appropriate hospice enrollment underscores how technology is emerging as a powerful ally. In an age where data-driven insights are becoming essential, AI tools provide us with opportunities to identify patients who would benefit from hospice or end-of-life care earlier in their healthcare journey. For case managers, this means we can better advocate for timely interventions that support comfort, reduce unnecessary care and foster informed decision-making for both patients and families.
Addressing Mental Health in Aging Adults
As this edition addresses, suicidal ideation among older adults is an issue that requires urgent attention and sensitivity. Often underrecognized, mental health struggles in seniors can stem from isolation, loss, chronic illness or fear of becoming a burden. As case managers, we are uniquely positioned to screen for these concerns, connect patients to behavioral health resources and coordinate care plans that address both physical and psychological well-being. This work requires collaboration, vigilance and an understanding of the holistic needs of this population.
Empowering Patients and Families with Planning Tools
The inclusion of articles on living wills, POLST (Physician Orders for Life-Sustaining Treatment) and estate and long-term care planning underscores the importance of proactive conversations about goals of care. As case managers, we often initiate these discussions, helping patients and families make decisions that align with their values and preferences. Tools like POLST provide clarity in moments of crisis and ensure that healthcare teams deliver care consistent with a patient’s wishes.
Further, as highlighted by discussions on the EPPLE Act in California, legislative and policy advancements can empower individuals to plan for end-of-life care more effectively. Staying informed on these topics enables case managers to remain valuable resources for families navigating these complex decisions.
The Emerging Role of End-of-Life Doulas
This edition also introduces readers to the role of end-of-life doulas—a growing field that complements hospice care by providing additional emotional and spiritual support for patients and families. This holistic, person-centered approach mirrors the heart of case management: ensuring every individual’s journey is met with dignity, respect and care.
Together, We Power the Future of Healthcare
As case managers, we are more than coordinators of care; we are educators, advocates and leaders in promoting solutions that meet the evolving needs of seniors. Whether it’s connecting patients with PACE programs, helping families navigate long-term care options or facilitating frailty screenings to inform interventions, our work has a direct and lasting impact on patient outcomes.
The road ahead calls for innovation, collaboration and a renewed commitment to advocating for programs and policies that improve care for our aging population. Our patients and their families depend on us to bring clarity to complexity, compassion to challenges and dignity to decisions. Let’s embrace these opportunities to lead the way in geriatric and end-of-life care.
The power of case management lies in our ability to transform lives at every stage of the care continuum. By equipping ourselves with knowledge, fostering collaboration, and advocating for patient-centered solutions, we ensure that seniors and their families are supported with the care they deserve. Thank you for your continued commitment to making a difference in the lives of those we serve.
Dr. Colleen Morley-Grabowski, DNP, RN, CCM, CMAC, CMCN, ACM-RN, FCM, is the associate chief clinical operations officer, care continuum for University of Illinois Health System and the current immediate past president of the Case Management Society of America National Board of Directors and president-elect of CMSA Chicago. She has held positions in acute care as director of case management at several acute care facilities and managed care entities in Illinois, overseeing utilization review, case management and social services for over 14 years; piloting quality improvement initiatives focused on readmission reduction, care coordination through better communication and population health management. Her current passion is in the area of improving health literacy. She is the recipient of the CMSA Foundation Practice Improvement Award (2020) and ANA Illinois Practice Improvement Award (2020) for her work in this area. Dr. Morley also received the AAMCN Managed Care Nurse Leader of the Year in 2010 and the CMSA Fellow of Case Management designation in 2022. Her first book, A Practical Guide to Acute Care Case Management, published by Blue Bayou Press, was released in February 2022. Her second book, Practical Guide to Hospital Readmission Reduction, published by Blue Bayou Press was released in February 2024. Her third book, Practical Guide to Acute Care Case Management Leadership, is in the works, targeting publication in 2025. Dr. Morley celebrates 25 years of nursing experience and 20 years in case management in 2024. Her clinical specialties include med/surg, oncology and pediatric nursing. She received her ADN at South Suburban College in South Holland, Illinois; BSN at Jacksonville University in Jacksonville, Florida, MSN from Norwich University in Northfield, Vermont, and her DNP at Chamberlain College of Nursing.
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