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Improvisation and Client-Centered Professional Case Management

Treiger, Teresa M., RN-BC, MA, CCM, CHCQM, FABQAURP

doi: 10.1097/NCM.0000000000000363
Departments: The HeartBeat of Case Management

Teresa M. Treiger, RN-BC, MA, CCM, CHCQM, FABQAURP is a past president of CMSA and current director on the National Transitions of Care Coalition. She is Principal of Ascent Care Management, LLC, Quincy, MA, specializing in private client case management, education, program design, and writing. Her health care career has spanned across the continuum. She designed and implemented case management, transition of care, frequent emergency department utilization, and uncompensated care programs while at McKesson. Her clinical experience includes acute and rehabilitation care.

Address correspondence to Teresa M. Treiger, RN-BC, MA, CCM, CHCQM, FABQAURP, Ascent Care Management, Quincy, MA 02343 (

The intent of this column is meant to speak to the heart of case management: our joys, our struggles, and our lessons learned. Please send your thoughts and ideas to us so we may include them in future articles. Teresa M. Treiger at:

This column was inspired by the article “4 Rules of Improv and How They Relate to Customer Support” by Micah Bennett (

The author reports no conflicts of interest.

When you stop to think about it, life is the ultimate improvisation. Consider the term itself; you may initially think about it in a live entertainment setting. Although that is one context, improvisation applies to our day-to-day work as well. We may want to believe that our jobs are predictable, but the reality is that our workdays are never as smooth as we desire them to be. When our best laid plans take a detour, we improvise our next action accordingly (and at times perhaps somewhat grudgingly).

Most people recognize the name Tina Fey, a gifted actress, scriptwriter, and author. In her book, Bossypants, she lists her rules for improvisation as:

  1. Say yes,
  2. Say yes,
  3. Make statements, and
  4. There are no mistakes.

This got me to thinking: Should we apply Rules 1 and 2 in our work lives more? I am not proposing that we sacrifice our health and well-being in the name of never saying “no.” What I am implying is that we assume the attitude and approach of more “yes” in what we do. It is worth serious consideration. However, in the process of less “no,” we must improve our improvisation skills, specifically how we communicate. We must begin from a more deliberate and knowledge-based point. Let's look at Rules 1 and 2.

We must start from a place of understanding our clients' goals and concepts of success from our very first interaction. Only then can we focus our subsequent efforts to advance client-centered outcomes. We tend to get caught up in our workflows and software-driven checklists, and let's acknowledge there are important reasons for having those bumper pads (of sorts) in place. But we must distinguish the manner in which we accomplish our work versus how we document task completion. Our interactions, in and of themselves, are far more detailed than a checkbox ever conveys ... and that is the downfall of checkbox case management.

Begin from the position of being a well-informed case manager. Let's consider Rule 3—“Make statements” (or “Make meaningful statements” for our purposes). Once we identify our clients' basic concepts of positive/negative, good/bad, and success/failure, we have the opportunity to advance toward goals within the client-centered context. This mind-set must frame all of our interaction. For example:

  • Reframe initial introductions. Introduce yourself by name. Make your next words meaningful to your client by avoiding the “I am a case manager” statement. Quite honestly, this term is meaningless to most laypeople. Instead, convey the purpose of your visit. Be clear that you are there to help with (fill in the blank). I also caution against using the words “getting you out of the xyz.” These words convey a meaning that your client is simply a commodity to be moved out of one place and into another.
  • Focus on the person. Ask how the person feels and if he or she is up to having a brief conversation. Doing so places the person in the driver's seat. If it is not the best time for the person, ask when you should return (or call back). Forcing an interaction on someone who is not feeling well and prefers not to talk is not a constructive use of time. The patient is already in a powerless position; let's avoid stripping him or her of what may be their last vestige of control.
  • Make meaningful statements. When continuing a conversation, your next statement should explain, in basic terms, how you are going to help. Rather than “I am going to arrange for your SNF bed or home care or something else.” Consider this, “I will guide you to the next step in your recovery and will help make those arrangements with you.” That statement means something because it includes the client as part of the collaboration, rather than a victim of a workflow. Again, this focuses your efforts on what the client's wants/needs are and lets the person know you are there to facilitate, rather than to force.

Does this sound too basic? Perhaps, it is but I often uncover fractured communication when assessing client-facing interactions. As professional case managers, we must reframe our most basic conversations to be less about what we do and more about what a client wants and needs to be done.

I hear colleagues bemoan the drama of a transition plan gone awry. Then comes the inevitable client conflict when a plan they tentatively agreed to does not work out. On further analysis, I find that client priorities were either not identified or, worse, disregarded, as a driving concern for shaping the plan. This is problematic in settings along the entire care continuum. Investigating these occurrences uncovers a common response of “I asked whether a client has a preferred vendor or post-acute facility.” Although that is a start, it is not what client-centeredness is about. Mandated queries touch on the past and serve to inform the present. But using a preferred vendor does not transform what we do to a client-centered approach in and of itself.

Back to saying “yes.” On stage, improv scenes are given a context, such as “two people at a complicated map trying to find the desired train and route.” Each participant says “yes” by making statements and adding details that invites the other person to respond. Negative statements grind the improv to a halt. Now, apply this overlay to work situations. The ability to collaborate comes with an assumption that we have done our homework before making any statements. To effectively make meaningful statements, we must take time to prepare for conversations. This allows us an opportunity to move closer to client-centered goals because we go into the conversation knowing more about the person or at least knowing what questions need to be asked in order to understand the person's situation. In doing so, we reduce the chances of giving a negative response that shuts down our case manager–client collaboration. Knowledge drives our meaningful interactions.

Most people work according to policies, workflows, and procedures. These build in “no” options simply by placing boundaries on our actions. For instance, consider a client who responds to statements about transition planning with an emphatic “I want to go home.” Rather than coming back with “You need to spend time in a rehab hospital first” (basically saying no with more words), how about saying “I understand wanting to go home, let's talk this through.” Follow this with open-ended questions to determine whether the person believes he or she will be safe going straight home, whether he or she has support systems, and perhaps adding in a few facts as to the person's current health state and self-care ability. Once you and the client have more information, you need to apply these new details and consider whether a home plan is a safe alternative. Avoid a showdown by giving the person a chance to think about your conversation. Let your client know you are going to reconsider the options and ask him or her to think about the possibility of a couple days of rehabilitation. This is where authentic client-centeredness begins. This also allows the conversation to continue versus ending it with an outright “no.” Our statements have meaning beyond definition. At best, they signal collaboration. At worst, they condescend and corrupt case manager–client trust.

Taking a “say yes” approach means making meaningful statements in order to build client trust. Serving as a facilitator means being there to help our clients achieve their goals. When we take a carefully considered approach, we begin to address Rule 4: There are no mistakes. We avoid the mistake of not understanding basic concepts of positive/negative, good/bad, and success/failure from our client's perspective. We avoid forcing a person into a transition plan that might let us check off a box but does not take client desires into account.

Can we completely avoid making mistakes? That is unlikely. However, in taking the time to consider information gleaned from our meaningful conversations, we may avoid falling into the trap of our work being reduced to as a checklist. Instead, the checklist becomes an essential safety mechanism. Today's professional case management shifts us into to a collaborative and creative client-centered practice, supporting clients as they strive toward their own goals.

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