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Rural case managers give health plan a local presence
CMs succeed with creativity, understanding
When a case manager for Presbyterian Health Plan couldn't get in touch with a family with two young children with serious health problems, she packed a lunch, charged up her cell phone, drove to the small New Mexico town on the Mexican border where she thought the family lived, and went door-to-door looking for them.
Her perseverance paid off. She found the family and was able to make a home visit to ensure that the children's mother was following the plan of care and the children were doing well.
Presbyterian Health Plan, with headquarters in Albuquerque, has 10 rural case managers who live throughout the state and serve the health plan's members in rural areas.
"Most of New Mexico is rural. Because we have a statewide presence, we cover a lot of sparsely populated areas," says Jean Calhoun, BSN, MSN, clinical director for the case management program.
Presbyterian Health Plan (PHP) serves just fewer than 300,000 covered lives spread across the entire state of New Mexico.
The plan serves a socioeconomically and ethnically diverse population. Many of their members live in rural areas with few health care resources.
The state's population is 30% Hispanic, and more than 60% of them are served by PHP's Salud Medicaid program.
There is a scattered Native American population, many of whom are served by Indian Health Services. About 2% of the Native American population is enrolled in Presbyterian Salud.
The rural case managers handle everything the health plan covers except transplants. That highly specialized area is handled from the Albuquerque headquarters.
They manage members with high-risk chronic diseases, as well as adults and children with special health care needs. They have been cross-trained to provide disease case management for members in their area with asthma or diabetes.
The case managers are divided along population lines and are assigned by geographic regions.
"We watch the caseloads carefully; and if they seem to be getting high, we quiz them about whether they need to close cases or whether there's been an influx of need in the area. If so, we adjust the caseload," Calhoun says.
When PHP was recruiting nurses for its rural case management program, the plan advertised strictly in the local newspaper in the areas it wanted to serve.
The plan's goal was to hire case managers who live in the region, are familiar with the local people, and know how to approach the members.
"An effective case manager in rural areas is someone who understand the local flavor and customs of the area. Some towns are on the international or state borders and people fade in and out on a frequent basis. If they don't want to be found, they can disappear," says Paula Casey, BSN, MSN, senior clinical project coordinator for case management.
Rural people, particularly those who live in poverty, are wary of people from the city and have the impression that urban dwellers tend to look down on them.
"If a member is contacted by someone down the road, they feel more comfortable, and feel like the case manager is on their level and isn't coming from the big city," Casey adds.
The nurse case managers know the providers, the people in the community, and the health care and social resources in the area. They know the members by first name and often meet them in the grocery store, Calhoun says.
In fact, some members are so comfortable with the case managers that they have to be reminded not to talk about their health problems in a public place, she adds.
In many areas, case managers have to get very creative to reach their clients, particularly for the first evaluation. Many don't have telephones, running water, or electricity, Casey points out.
"The members in our Medicaid HMO program are a nomadic group. They may have a telephone today and no telephone tomorrow. Some move back and forth across the Mexican border," Casey says.
To locate their clients in the far-flung rural areas, the case managers start with the primary care physician's office, hoping to find an address or phone number.
If the person doesn't have a telephone, the case manager sends him or her a letter. In some cases, they choose to send a registered letter to make sure it gets delivered. The registered letters get good results, but it's expensive if the case managers have to send a lot of them, Calhoun points out.
"We have good success sending out a letter saying that we have been trying to reach them and asking them to call to talk to the case manager about their health," Casey says.
Most of the members have a neighbor whose telephone they can borrow. Before the Health Insurance Portability and Accountability Act (HIPAA) went into effect, some case managers would post notes for the member in the general store on the Indian reservation.
"Now, because of patient confidentiality mandated by HIPAA, that may be a challenge," Calhoun points out.
When case managers leave telephone messages, they say it's a courtesy call from the health plan and leave a telephone number.
With the Hispanic population, they avoid saying the call is from Salud because many people don't want it publicized that their family receives Medicaid benefits.
The case managers often use their creativity in meeting the needs of the members. They often encounter challenges not faced by their counterparts in the city.
For instance, when the health plan made its Y2K preparations, generator and backup generator were on the list of purchases for children at home on ventilators.
In another instance, one young girl with cerebral palsy was unable to manipulate her electric wheelchair over the bumpy dirt roads and the pastures on the Navajo reservation where she lived. Her family were sheepherders, and the young girl wanted to be able to help with the family's sheep.
The case manager was able to get her wheelchair modified with wider wheels that would allow her to go over rough terrain and help with the family's sheep.
The local television news did a story about the girl and her new wheelchair.
"Just the smile on that little girl's face as she helped herd sheep in her wheelchair was worth all the effort. Meeting the needs of people in rural areas is what we're all about," Calhoun says.