Members need help with all the details
Managing the care of an organ transplant patient requires a lot of coordination and communication among the transplant facility, the family, and the insurer.
That’s where Vickie Wrigley, RN, and Olivia Farrell, RN, come in.
They are medical management coordinators for Regence Blue Cross and Blue Shield of Oregon (BCBSO) who case manage all the transplant patients covered by the plan.
Most of the time, the case managers get involved when a member has been evaluated as a successful transplant candidate by a transplant facility.
But about 20% of the time, the case managers hear from the patient or a family member before the transplant facility is involved. They call in as soon as they get the news from their physician, wondering what they should do next.
"In those cases, we spend a lot of time calming people down. They’ve just gotten a diagnosis of a dying heart or acute leukemia and in addition to dealing with that, they’re worried about financing," Wrigley says.
The case managers talk mainly to family members, but some patients are very aggressive in trying to find out every detail about their illness and the transplant procedure.
Many of the questions involve benefits and what BCBSO will cover. "We are interpreters. We can turn their benefits legalese into plan English for them," Farrell says.
"The questions vary so much between people. It’s always constantly changing. We never know what the next question will be," Farrell says.
Farrell and Wrigley refer patients who need transplants to a transplant center, depending on their benefits.
"If the benefits require that they go within our national transplant network, I try to get them to the closest one or in a place where they have family," Farrell says.
For instance, she placed one member from southern Oregon at a transplant facility in Cleveland because that’s where he had family and friends.
The case managers follow the patients through the course of treatment and the recovery period, making sure the care is coordinated. When the patient is hospitalized, the transplant case managers communicate mainly with the transplant teams.
"I feel like, if they’re in the transplant center, that is where their care should be coordinated. The transplant facility case manager is in their room every day, and we don’t want to confuse them by having two people manage their care," Farrell says.
"We follow through with utilization review and concurrent review over the phone with the hospital case management for transplant. We make sure everything is going well and identify their discharge needs," Farrell says.
If the case managers feel that the care is not what it should be, they step in.
For instance, the mother of a baby who had a liver transplant called Regence because she was concerned about the care her baby was getting.
Farrell contacted the transplant team and discussed the issue. She then notified Regence’s credentialing facility. The credentialing facility set up an on-site review of the program to determine if Regence should continue its contract with that facility.
"We do make recommendations to change clinical practices at the transplant facility, but that very rarely happens," Farrell adds.
The case managers follow the transplant patients clinically to identify their discharge needs and to identify an inpatient rehabilitation facility or skilled nursing facility before the patient is discharged.
If patients goes home with home health services, the case managers monitor the patients’ progress and make sure they’re getting the services they need.
The case managers provide invaluable assistance to the home health and hospice team in the event that the transplant isn’t successful and the patient is terminal.
Case managers stay involved as long as the members need them — sometimes just six months and sometimes for two years.