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Good News Stories from The Health Plan

Jeanna Falbo: Monster Improvement in Healthy Choices

I began working with this member in May of 2022 when he opted into the DM program for assistance with his uncontrolled Diabetes. On our first call he informed me that he was not checking his blood sugar, taking insulin sporadically, smoking 2-2.5 packs of cigarettes/day and drinking 7-8 Regular Monster drinks/day. I educated him on following a diabetic diet and taking his medications as prescribed and sent him the DM Core content by e-mail. We both agreed that his goals would be to decrease his intake of Monster beverages from 8 cans/day to 4 cans or less/day, check his blood sugar at least bid and cover it with Novolog as ordered, and to administer 16 unit of Lantus SQ every evening. He had developed a diabetic ulcer on his left pinky toe, which was draining purulent fluid. I instructed him to visit Urgent Care so that it could be evaluated, he stated that he would. Also, he has Asthma and was not taking Symbicort as his rescue inhaler because the pharmacy would not refill his rescue inhaler. I spoke with the member’s pharmacy and his PCP so that the member could get his rescue inhaler refilled and begin taking the correct dosage of Symbicort (the pharmacy had given him 80-4.5 and he was actually ordered 160-4.5). Next, I contacted the member on 6/13/2022 and he was taking his medication as prescribed and reported feeling better overall. He was drinking 1 monster every 1-2 days and stated that he was sleeping better. However, he was not checking his blood sugars because he could not find his glucometer. I praised the member for making the lifestyle changes and encouraged him to keep up the good work. We agreed that his next goal would be to check his blood sugar at least daily. He did not visit urgent care for his toe ulcer but informed me that it was improving and no longer draining. When I next spoke with him on 6/21/2022 he informed me that he missed his PCP appointment on 6/20/2022. He claimed that the office would not call him back and the toe ulcer was not improving. I contacted his PCP and scheduled him for an appointment for 6/23/2022. I spoke with the member today and he is scheduled to begin seeing a podiatrist next week and has a return PCP visit scheduled in one month. He has started checking his blood sugars bid (200-260) and his A1C on 6/23/2022 was 11.0. His last A1C level was 11.2 on 8/4/2021. He has begun to make some small but significant lifestyle changes within the last month and is feeling better as a result. I plan on working more with this member more to assist him in achieving his healthcare goals, but I feel like I am really making a difference in his life already.

Michelle Tracy: Never Give Up

I started following a teenage SSI member with severe cerebral palsy in late 2018, after another case manager left. She was in the custody of her grandparents. She was in a power w/c and could not stand. She used a hoyer lift for transferring. She needed assistance with all activities of daily living. She could not sit without assistance. She received PT/OT at school. The guardian’s primary concern was problems with getting incontinence supplies. Her grandma only wanted a certain very specific kind that worked well for this member. I researched and called DME providers for the brand/type of incontinence supplies that the guardian wanted. Finally, the member was set up with the preferred, needed incontinence supplies, but upon follow up, I learned that they were arriving as a decreased amount. I again called the DME company, clarified the order and got the rest of the supplies delivered, only to find out the DME company put member’s account on hold for unclear reasons. Again, I called to straighten this out and ensure the family had what they need. There were many hoops to jump through, but the family ultimately met their primary goal for receiving supplies necessary to promote hygiene and prevent infections.

I also educated member’s grandma on the availability and steps for receiving a personal care aid and IDD waiver. Her grandma was adamant that member was turned down for IDD in the past, but I encouraged her to try again. I sent her the pamphlet and application for PCA and IDD for consideration. The member also needed a new wheelchair with certain modifications, I provided guidance, support and information to get these approved as they were medically necessary for this member to achieve and maintain optimum mobility and community interaction. Then there were incontinence supply issues again! I called DME companies, but none had the name brand the member needed, however some DME companies were willing to send samples for the family to try and the grandma was agreeable to trying alternative products as a last resort.

At this point, Grandma was now ready to fill out the IDD waiver application and willing to appeal if denied. The forms were completed and submitted with assistance. The member had all needed DME and was familiar with the process for reordering supplies. This member’s goals were met, so I closed her case. The member’s grandma was reluctant to close case at first but stated she would call and keep me updated if anything changed. I assured her I had every confidence in her ability to now manage the member’s needs, but that she could call me anytime she wanted to talk. I received a call from member’s grandma 2 months after closing case. She wanted me to be the first person she told; her granddaughter had been approved for the very needed IDD waiver. She asked me to explain what happens next in the process and I did this to the best of my ability. She stated she never should have listened to the DHHR worker who told her that the member would not qualify for IDD because she has SSI. She is glad she listened to me and enrolled in case management with THP. She then stated her husband is now retired and they are on a fixed income. She stated their van w/c lift was broken and would be $6000 to fix. I educated her and provided her with information on the Family Grant and a couple other resources that may be able to help meet their current needs to ensure that transportation is possible. She was very thankful for all the information, stated she loves me and will continue to call me with any further updates or questions.

Todd Ullom: Bear Man’s Baby

There was a 6-month-old MHT TANF member hospitalized d/t failure to thrive referred to case management during an inpatient stay. He had other diagnosis including Prader Willi Syndrome, positional plagiocephaly (a flat head from being left in the lying on his back), hypotonia, cradle cap and hip dysplasia. The hospital clinical information noted that the staff were repeatedly having to remind the mother that the child needs to be fed regularly and that the mother was frequently found sleeping or being non-attentive to the child and their feeding needs. Working with the hospital, a discharge plan was made to discharge the infants with the grandparents. When I contacted the grandfather, it turned out he was actually the Great Grandfather. The child’s mother (his granddaughter) was also living with them and would remain involved in the care of the child at this point. The great grandparents were agreeable to supervising the care to ensure the child received all he needed.

I quickly formed a good relationship with the Great Grandfather who gave me an in-depth background on child’s mother who he described as a rebellious child who “still had a lot of growing up to do.” He spoke of her father (his own son) who he described the same way, stating he “just lived to party, with no plans in life”. The granddaughter’s mother was not in the picture at all. The Great Grandfather had always worked and had some interesting escapades himself, having encounters with bears and even a rattlesnake bite story that he took pride in sharing with me. I nicknamed him the “Bear Man” from an article he sent to me at the office that was written about him and continued to work with him to help coordinate care for his great grandchild.

The infant grandson was sent home with tube feeds but would receive oral feeds which were increased over time. I educated the family and insured they were set up with WIC, Birth to Three and received an application for Children with Special Health Care Needs. I mostly spoke with the Great Grandfather, but occasionally had the opportunity to speak with the mother. She always just stated that all was well with the child and that there were no needs and no concerns on her part. But, as I spoke with Great Grandfather, I was informed of CPS involvement and daily visits occurring. The Great Grandfather was becoming worried of the child’s status and did not want to have the child taken due to the mother’s actions/lifestyle. He began calling me regularly with his concerns about CPS and their plans for the child. I informed him I was not with CPS, and he just needs to speak with them openly and honestly and let his intentions and concerns to be known to them. While I certainly provided guidance about infant care, feeding, well visits, immunizations and dental care, at times, I was there just to explain certain processes to him and that eased his mind or be a sounding board or someone to talk to.

At one point in time, I phoned the house to check in and follow up on the child’s care and learned that the mother left their house and had not returned home. CPS was at that time, attempting to obtain a medical card for the child that grandparents can use. I listened to all of the concerns voiced by Great Grandfather and assured him it was important to keep in close contact with CPS about the matter and follow up with the DHHR to explain the current situation to them. He thanked me for always being supportive and providing direction. Eventually, there was a court hearing, and the Great Grandparents were given temporary custody with mother receiving 2 hour supervised visitation at the local YWCA. The Great Grandfather kept me informed more often than I had calls scheduled. Sometimes he just needed someone to talk to. The child flourished under their care and his G tube was removed. He was active and on track developmentally and receiving visits from Birth to Three for continued assessment and therapy. Custody hearings continued and child eventually termed with THP. The Great Grandfather called me at that point, just wanting to inform me they were adopting the child as their own. He expressed that he was so pleased. He now knew the child would be safe and cared for. He was proud that all that is his will pass on to the child.

Now, 4 years after their services ended with THP, I recently received a call with a man asking “Todd, do you know who I am?”. I knew the voice and answered quickly, “It’s the Bear Man!”. He laughed, acknowledged this and said he was just calling to tell me his grandson is doing great; he is active at preschool and in church. He stated he and his wife just wanted to thank me for all that I did for them those years ago, just being there when he felt lost and alone in the process of trying to establish guardianship. I was so appreciative of his words and very glad to hear his (now) son (previously great grandson) is doing so well. A good outcome for a family makes all the hours of case management worthwhile.

Sheri Meyer: Over and Above

Sharing the wonderful news that, with much persistence, one of my chronic disease managed members was approved for a much needed, new electric mobility scooter with the tilt and recline features he needs to manage his lymphedema. This is major news because he had a scooter that he got just a few years ago that they could not adapt for his new diagnoses and the motors have been repaired and replaced so many times that his DME providers did not feel they could do any more with it. I was very concerned that the new scooter would not be covered due to it being less than five years (RUL) since he got the last one.

He reported a reemergence of a chronic ulcer to his right foot in February of this year that was worse than any of the others. He was getting treatment from his wound care specialist. Treatment was aggravated by chronic weeping lymphedema in both legs which required dressing changes twice daily. He required dressings over and above what was allowed and with my supervisor’s assistance I got that authorized and I switched him to a new home DME delivery per his request due to issues receiving his supplies in a timely manner.

Unfortunately, his was admitted to the hospital in March with new onset of CHF and sepsis from the wound. The doctors in the hospital and his PCP all felt his problems were being aggravated by his scooter in which he spends most of the day. His legs were heavily dependent, and the wound was further compromised by the weight of his leg. They all recommended he should have a chair that allowed him to recline and elevate his legs.

His old chair had been ordered by his podiatrist. Issues had arisen for repairs being authorized in the past due to this doctor not having all the clinical records. I suggested having his PCP order the chair and worked with her to initiate this. The process began. The specialized wheelchair DME provider consulted me several times asking what was needed to get all clinical data together prior to submitting the request, such as the PT evaluation. I researched and advised her that yes, it was best to go into it fully prepared. I called the member and explained to him how important it was for him to go to the eval and be cooperative with everything they asked him to do since he had been very reluctant to participate in PT in the past due to severe knee pain. He finally understood that this was necessary to establish his physical limitations and why he needed to have the scooter. They were able to observe his lack of balance and inability to stand for even brief periods, let alone ambulate.

The eval was completed and sent back to the PCP who was unfortunately out of the office on leave or vacation for a few weeks and she was the only one who could sign the order, so we waited patiently for her return. It was signed and submitted upon her return with fingers crossed. We all expected a non-authorization but were prepared for the appeal process if needed. Needless to say, we were all stunned to find that the documentation met medical necessity for this very specific need and the scooter had been approved on the first attempt! I was grateful to the doctor for the meticulous documentation and the DME company for working with me on proper preparation of the request.

I had the pleasure of calling and giving him the good the news and he was “dumbfounded” and so happy to hear the good news. He said this will definitely change the quality of his life!

He just happened to be leaving his PCP’s office at the time I called, and she told him he had lost an additional five pounds, so he is down to 379# now for an almost 40# weight loss. She was immensely pleased with him and the progress he has made. His insulin dose was lowered from 15 units to 10 units. He is highly motivated to continue to lose more weight.

He also told me he had gotten approved for assistance for his prescription for Santyl for wound care from the manufacturer. I had found the application on the website and told his wound care provider about it, and they did submit the paperwork for assistance. Santyl is no longer formulary with MHT, and he could not afford it out of pocket.

Every member has unique and specific needs that sometimes may exceed the standard limitations or authorization rules set for the general public. Part of case managing is advocating for your member to make sure they have the medications, supplies and tools that are supplied in the correct quantity and best timing for them.


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