Michelle Tracy: Care Across the Spectrum
I cased managed a young lady who had been admitted to the hospital for craniotomy to remove a tumor. After surgery she had a mental status change and CT revealed blood throughout with midline shift. She had an inpatient course and was on vent, taken back to OR, had burr holes, ended up with PEG tube and trach. During the entire inpatient stay discharge disposition was planned for SNF. She was instead sent home.
We authorized hospital bed, hoyer lift, daily tube feeds, suction machine, trach supplies, oxygen, and manual wheelchair. I called and spoke to the member’s mom and husband. The husband had visited the SNF and decided it was not the right place for his wife and wanted to take her home. She was comatose, unable to communicate. Hospital bed and hoyer lift were not delivered before she arrived home. I did much education on elevating the member’s head for tube feedings, turning and positioning. They had bought enteral formula online. I told the mom THP would pay for the tube feed formula based on medical necessity for this member. I called Bioscrips and explained THP would pay for the enteral formula since it was only means of nutrition. I got this all taken care of and authorized. I then called and got paperwork started for incontinent supplies. The Dr. was not signing the rx for incontinent supplies so I called the office and they had the Dr. sign paperwork and faxed it back to DME company so member could get supplies. I educated the family on personal care aid and waiver programs. I consulted the THP social worker who helped with applications for PCA and ADW, both were approved (the husband ended up declining these services). Home Health was ordered but had told the family that with Medicaid they could only have 5 visits, so the nurse was only going to the home 1x a week. I informed them that this was not true for managed care. I called the HH agency and educated them on home health benefit and asked that they see member at least 3x a week, which they ended up doing immediately. I asked for home health physical and occupational therapies to see the member along with an aide to help with personal care, which they provided. The family was overwhelmed and didn’t even understand the meds. They cried off and on with every conversation and required a great deal of emotional support as well as education.
There were transportation issues and I had to call the ambulance service to set up and find out why they were denying transport. Transportation was resolved. I referred the member to disability outreach to help the family through the SSI application process. There were additionally problems filling her Lovenox. I had to work on getting the Lovenox to the pharmacy and Dr. office for administration to prevent blood clots. After about a month home, she had progressed and her trach was taken out. After another month, the member was alert enough to go to acute rehab. I made arrangements and member did well there. She started eating and slowly started feeding herself.
Then, member fell off THP for about 6 months, her family was not happy. I continued to receive calls from them. When her mom knew she was coming back on THP she called and said she wanted me to be the case manager again. I opened the case and reassessed the member and her progress. The member had surgery to replace missing skull sections. Her g-tube was taken out. She was feeding herself. Her family could now transport her to appointments. She was going to outpatient therapies. She still could not walk and needed a one person assist to transfer. They were getting bills from a DME provider. I called the DME provider and explained they needed to bill FFS for the time member was not on THP and educated that is not permissible to bill the member. I educated the family again on PCA and ADW and this time the mom was interested. Member was supported through application process and approved for both. She is awaiting an aide to be hired to provide the care she needs. She is now receiving SSI. With continued therapy, she has now started to walk and is learning to get out of chair and bed by herself. This member has made great strides during the 3 years I followed her. I have recently discharged her and closed her case with all interventions complete and all goals met. The mom stated to me that she has my number and will not hesitate to call with any questions or needs.
Connie Milburn: Not Diabetes, But So Much More
Member was referred for chronic disease management with a risk stratification of moderate clinical risk -moderate actionable opportunity. I reviewed her claims and found an A1C had been ordered on 2/25/2022. I could not find any medications for diabetes or a diabetes or prediabetes diagnosis. I called the office of her PCP and found that the member did not have a diabetes diagnosis, but due to morbid obesity her PCP ordered the A1C. She gave the 2/25/22 result showing an A1C of 5.3%. I requested the medical records for a hard copy of the result. I placed a call to the member and she answered. She explained to me that she had a laminectomy in the past and over time has developed muscle wasting, weakness and atrophy and continues to experience radiculopathy in the buttock and down her leg. Her two children live with her, and their father recently passed away unexpectedly. Member had a walker and cane in her home for mobility, but felt very shaky and unstable when she tried to use them. She becomes weak and has pain with only walking a few steps. She does experience falls from the weakness. Her daughter is 15 y/o and her son is 14 y/o. Her son suffers from ADD, ADHD, and ODD. He will often punch the walls with his fists. She has to rely on her children to help with cleaning and cooking which is a challenge. She reports they mostly use the air fryer and microwave to make the meals. There are some meals they can cook on the stove. She became tearful as she explained that her daughter helps her dress and assists with bathing, and her son will help with lifting her from the chair and toilet. She said “they should be out having fun and being teenagers. I cannot attend any of their activities.” She said that she had hired a lady to come in and clean and do the laundry, but she really cannot afford to pay her. She has an assessment for a powered wheelchair coming up, and PT is working to get it through a contracted DME provider. She has tried PT/OT but it increases her pain. She has been referred to pain management at Cabell Huntington to be assessed for a pain pump. She has a license and a car, but she is afraid to drive due to the medications she is on. She will drive her children 9/10 of a mile down the lane on cold days, to catch the bus, but it is all she can do to get to the car with their help. Her boyfriend takes her to her appointments, which she will schedule on his days off, on Fridays. He will also have them over to his house on the weekends, which gives the kids a little break from cooking. She reports that she has been able to cover her utilities, but last month she had an estimated heating bill for $500 and she was able to pay it with her tax return. Her house is sound, and currently in no need of repairs, except for the holes that her son punched in the walls. She has a h/o Celiac disease, which is hard to control considering her diet. She has urinary incontinence since the surgery and is requiring incontinence pads. She is applying for disability and has a hearing on 6/1/22. She asked about a wheelchair ramp to make it easier to get her in and out of the house, and assistance with cleaning, cooking, shopping, and personal care. I spoke with Mary Coleman SW and told her about this member’s needs. Mary was willing to join the THP care team and contact and assist her. Mary reached out to her and discussed the need and process for getting personal care. She agreed to have a referral made to the Coordinated Council for Independent Living to assist with the personal care application. She identified potential needs with bathing, dressing, and cleaning. They discussed need for a wheelchair ramp and provided connection to the WV Center for Independent Living to see if they have any funds or programs to assist. Member’s case is in process and remains open with many goals and interventions still in process, but I thought this story was important to share to demonstrate that a risk stratification and thorough assessment uncovered multiple needs that would not have been identified by a diagnosis like diabetes alone.
Sheri Meyer and Cindy Schumacher: Shared Praise From a Member to Outreach Advocate, Misty Smith That Uncovered Excellent Care Coordination:
Misty Smith: I just wanted to reach out and let you know that I just called “member” & her “husband” for their annual HRAs. While speaking to member, she more than raved about Sheri & Cindy and all their help during her recovery from open heart surgery. Several times she mentioned what a great job they did and how happy she was with both. Then her husband backed it up while I was speaking with him. It’s not very often that we hear such enthusiastic praise from a single family so I wanted to let you know how very pleased they both are with Sheri & Cindy.
Sheri: In May 2021, I received an activity for a 73 year old SecureCare member who had had a CABG. I called her for possible enrollment in the disease management program and learned that she also had a history of rheumatoid arthritis. I initially consulted with Cindy Schumacher due to the diagnosis of RA and we decided that I would continue to follow up with her and let Cindy know if any complications develop related to the RA. She had not had any previous history of coronary artery disease and had been on Enbrel, methotrexate and prednisone prior to needing surgery. These meds were held for the surgery. My initial contact was made about two weeks after her discharge and she was doing well. The discharge summary reported that her incisions were well approximated and was to resume her medications for her RA. Home health care had been ordered, but when I spoke to her she said that she had not received that service. I did contact her PCP and they did order nursing and physical therapy for her which she did need to improve her stamina following surgery. She was a very pleasant lady, very open to education but also very knowledgeable about her health. I mainly offered empathy and support and asked what her needs were and tried to get her the assistance that was most important for her recovery.
Over the next few months, she had poor healing of the sternal wound possibly due to her medications for RA and went through several courses of antibiotics. A wound vac was placed by the surgeon to aid in the healing. Home Health nursing remained in place to help her with wound care. She had to stop taking her medications for RA again which set her back physically and was not able to complete cardiac rehab. She was very frustrated because she felt as if she was recovering from the heart surgery and wanted to be more active. I continued to offer support and education calling monthly to follow up on her progress. She would call me after her appointments to update me as well. By late August her sternal wound had healed. She was able to start her RA meds again and felt healthy and able to resume her normal activities. Cindy and I agreed it was safe to close her case as goals met. If she had any further needs she would be more appropriate for case management and Cindy would take over.
Sadly in Sept, she called again to report that the wound had opened once again and this time the surgeon reopened the wound to clean it and again placed a wound vac. I notified Cindy of the readmission and she assumed care.
Cindy’s note: When I began to work with this very nice member she had been having difficulty getting the Wound VAC delivered. I was able to contact KCI and get a firm date of delivery to member’s home. Fortunately, this was delivered prior to the weekend so a HHC nurse was able to get it applied. This is especially important as member’s daughter was going to assist with dressing changes over the weekend, if the Wound VAC was not in place. Member told me her daughter would do it but was not looking forward to it as she is “squeamish”. I spoke with member yesterday who told me her sternal wound did finally heal by the next month. She was very appreciative of Sheri’s assistance and for my part in helping with the Wound VAC delivery. She said THP has never denied her anything and she feels fortunate to have this insurance.