Special Needs by Todd Ullom
I was referred to a Medicaid TANF CSHCN member who was born by emergent C section at 23 wk 3d due to placenta previa to a 32 year old mother. Mother was incarcerated at the time. Baby was diagnosed with extreme prematurity, Bronchpulmonary dysplasia, Retinopathy Of Prematurity, right rib fracture, PVL ( periventricular leukomalacia),and Ventricular Septal Defect. The member was transferred to Nationwide Children’s Hospital for a higher level of care where they stayed almost 2 years due to complexity of care and social situation. During that stay, the baby was vent dependent as well as dependent on enteral feeds. Child was not showing much response to treatment or improvement in functional status. I attempted contact and integration with several UR/CM staff at Nationwide as well as the family (who was not responding to contact, with mother still incarcerated), but staff changed several times over the course of the stay and coordination was difficult. Per requested clinicals, the member’s prognosis was very grim. The child was not tolerating much stimuli and was having frequent episodes of desaturation; I feared the child would not survive. It was at this low point the child was transferred to another department within NCH and began to respond to treatment and show slow improvement. The child was assigned a new discharge planner, who I contacted and was able to work with to begin discussing early discharge plans and reintegration back into a home setting. I facilitated setting up PDN (Private Duty Nursing) services through Maxim. I had approached two providers, Maxim and Interim, early on as it can take up to 6 months to get established with PDN based on the hours needed and type of care required due to the rural area in which the member lives and available staffing. I also worked with Nationwide’s CM to assess the member and family needs and ensure that all of the medical equipment, respiratory and enteral supplies were available for a planned return to home when the member and family were deemed ready.
By this time, the member’s parents were present at the hospital, involved in discharge planning and receiving home-care teaching from on-site hospital staff. After multiple unsuccessful attempts to contact parents in the home setting, I was finally able to speak with the mother (who was now out on parole) and although the father’s previous status had been unclear, I was now able to confirm his involvement too. When finally speaking with them, they realized I was here to help support them in any way I could and help them build care skills and gain resources to best care for their child in their home. With care coordinated by THP, NCH and family buy in, discharge from Nationwide to home was finally set to occur. It was at this point, that the member’s mother informed me of another hurdle. There was some confusion at the hospital due to mom’s incarceration status, the baby’s name at birth and the social security number. The child had been listed as another name at birth and the birth records were not clear to establish a birth certificate and to get a social security number. Through case management I was able to provide instructions to the family for clarifying information and guiding her to be able to establish appropriate documentation and facilitate obtaining a birth certificate. Another small hurdle I was able to help the family overcome was that the DHHR had created two different accounts for member, which required some support and interaction with the state to clarify and merge records.
Currently, this member has a safe home, attentive caregivers and all needed supplies and services. This family is interactive with care coordination and attending all appointments. The member continues to do well with enteral feedings and PDN services despite the complications of managing vent dependency. The child is receiving physical therapy and speech therapy and is working toward the goal of being able to discontinue enteral feeds in the future. The mother is optimistic for child to be weaned from ventilator in the future as well. The child is very active and the physician and caregivers always describe a pleasant, happy, well cared for child.
Readiness to Change by Sheri Meyer
I received this member as a referral for COPD education from Bobbi Rauschenberg and initially contacted her in January offering her the DM program for COPD. She was very receptive and we spent time talking and offered her many tips on controlling her breathing, mailing Core Content articles to her since we did not have the program ready for email yet. I reinforced the importance of smoking cessation and encouraged her to consider pulmonary rehab. Bobbi was also continuing to follow up with her to get her prescription for generic Chantix approved. The member was very worried about a CT scan her doctor had ordered which turned out to be a screening for lung cancer. She was frightened that it would show she had cancer. I reviewed the results which fortunately were negative and called her for follow up. She told me that is what her doctor said but she had been wondering if she needed a second opinion! It made her feel so much better to know that I had read the report and telling her the same thing.
During our chat yesterday she was proud to say she had not had a cigarette in five days! Her family was being supportive of her this time by not smoking around her making it easier for her to stick with it. She had thought about my suggestion for pulmonary rehab and decided to ask her pulmonologist about that because she wants to be able to go hiking again and knows she can’t do that the way she is breathing now. I encouraged her to work toward this goal.
She asked for my help with her nebulizer saying it was making an awful noise and she was afraid to use it but really needed it. She was sharing her husband’s and sometimes they needed it at the same time. She turned her nebulizer on for me and I could hear that it sounded like a WWII prop engine about to blow! She said she had been asking her PCP for a new one for almost a year and was still waiting. I suggested she call her husband’s DME company first and see if they were a provider for nebulizers but they said that they were not. I told her I would try to contact her doctor and get a new one prescribed for her. Since she has a new pulmonologist I thought it would be best to start there and found a claim for albuterol for nebulizer with his name as the prescriber and called his office. The staff was very nice and did confirm her as a patient and were very receptive to my request and said they would contact her today to ask which DME company she preferred and get a new nebulizer prescribed. I called the member back with the good news and she was relieved and grateful, calling me her angel.
I had updated Bobbi on the member’s progress, calling her a success story in progress for both of us, which is very rare for COPD members. I look forward to continuing to follow up with her and hearing that she is ready to go hiking!
Member Experience Survey Response submitted by Kim Jordan on behalf of Michelle Tracy
While working the CM Program Member Experience Survey Red Flag Alert file follow up, a MHT member’s mother was identified as completing the survey by telephone on 3/7/2022 on behalf of her daughter. She answered “10 Excellent” (highest score) to questions pertaining to her CM experience. She did, however, indicate she had a health care concern or question for a THP representative and requested a callback. As per our process, I referred this to her recent CM, Michelle Tracy. Michelle called her and the mother asked to speak to Michelle’s manager, instead. I called her back, immediately. She had no questions or concerns but instead wanted to tell me that she didn’t know such service as case management existed prior to her daughter’s birth. Michelle had provided her with educational support, benefit information and overall kindness. “Michelle made the last 3 years bearable”, she stated, with all she had going on with her daughter. She just wanted THP to know how much she appreciated Michelle and her services. She felt like she was “not just a number” or ”another name on the list”. She stated that Michelle was so knowledgeable of milestones, growth and development as well as associated benefits and services that she just wanted someone in management to know what a great service this was and how grateful she was for Michelle. She stated it had been a long 3 years, but she described case management as “like an aunt calling to support her and help her”. While they had just mutually agreed to close the program with all goals met, I reiterated she could call Michelle or myself anytime a new need or question arises. She thanked me again for the service provided to her family.
Case Closure Note from Care Coordination System: Yearly update for 3 year old female member born at 26wk 1d via emergency Csection d/t placenta separation. I called (phone number) and spoke to member's mom. She states member doing great. She transitioned from Birth to 3 to school, special needs program and has an IEP. She stated she gets PT/OT/ST and developmental at school. She is very happy with school, goes Monday through Friday 8-12:30. She is not potty trained and is getting incontinent supplies from Aeroflow. Member knows her name, age, sex, knows her colors, can count to 15, can run and climb. She cannot talk in sentences, only 2 words at a time. She does not dress/undress, know friends name. She toe walks at this time and I let mom know PT will work on this, she stated that that is a priority they are working on now. Member's appetite is normal. She eats 3 meals, fruits, vegetables, milk, and decreased sugary drinks. She is established with a dentist and mom asked how often she should go. I educated dental visits are usually every 6 months, she stated ok. They have plenty of food. Able to pay the utilities and bills. Live in a safe, clean home and no abuse. Mom states member gets disability and this has helped. I educated mom on IDD Waiver program and that she can actually provide the care if qualifies. I emailed her this information at (personal email address) while we were talking and she acknowledged getting it and will look into this. Mom is agreeable with case closing, goals met, no further needs at this time. She has my number and will call with any future questions, needs. Mom thanked me for advising and caring for them for the last 3 years.