Pediatric cancer patients present challenges
Pediatric cancer patients present challenges
Wide range of payers and benefits must be tracked
As a case manager for pediatric cancer patients, Mary Nugent, RN, is challenged with ensuring that her patients get the care and equipment they need when they are out of the hospital, a job that is made more difficult by the scarcity of some of the medications the children are prescribed and the wide range of payers and benefits.
"These patients are not like those on other pediatric floors, when the child comes in with an illness or following surgery and you never see them again. These kids are in and out of the hospital frequently, and they have intensive discharge planning needs," says Nugent, a case manager at Aflac Cancer Center and Blood Disorders Service at Children’s Healthcare of Atlanta.
The cancer center has 16 beds. In addition, Nugent manages the care for patients in four beds on the neurosurgical floor.
"There’s a huge difference between pediatric patients and adult patients. Pediatric patients, particularly those with cancer, have so many discharge planning needs. Cancer becomes their whole life, and they all become like our extended family," she says.
One of her biggest challenges is making sure that the children get the medication they are prescribed when they are discharged. Her young cancer patients are in and out of the hospital all the time and often have their multiple medications changed with each visit. She is responsible for obtaining prior authorization for medication if it’s needed and spends a lot of time calling drugstores to make sure they have the required drugs.
"These children are on multiple medications that often change frequently," she says. "These medications can be expensive and hard to find. The challenge comes because these are off-target medications, and some insurers don’t want to pay for them. I don’t send the children out the door unless I’m sure the medication will be available. Sometimes, I have the medication sent by courier to the hospital for teaching. Nobody goes home with no prescriptions."
The children covered by Medicaid present a whole different set of challenges. For instance, Medicaid will allow only 12 doses for Zofran, a commonly used medication for nausea and vomiting. Nugent often has to get an override for her patients, who usually need more than 12 doses.
On a day-to-day basis, Nugent checks prior authorization requirements for medication.
"I spend a lot of time checking with payers and Medicaid and working to get authorizations if we don’t already have them," she says.
Nugent’s job has become more difficult in recent years because of prior authorization requirements and Medicaid funding cuts.
"The rules are changing. It’s best for the child if we take care of all the issues before they leave the hospital," she says.
The pediatric cancer patients are closely monitored when they are at home.
"Knowing what each payer will cover creates a lot of challenges. Home health care is a constant for these children. They typically have labs drawn twice a week and they have IV lines. I start with the best-case scenario, which is having this done at home," she says.
"They are on some kind of protocol for chemotherapy, and their blood counts dictate whether they are proceeding along as they should be or if we should hold the chemo," she says.
Many of the children are self-pay, and they often can’t be discharged because they can’t pay for the medication or supplies they need.
"We have to do a lot of creative things. We don’t necessarily buy things for them, but we try to work it out," she says.
For instance, the parents of an out-of-town patient arranged for the child to get his subcutaneous injections at the local fire station. The medication didn’t require precertification, but the insurance wouldn’t cover the syringe. The pharmacy ended up giving the family the syringe that was needed.
Because of her knowledge of the children she works with as inpatients, she also gets calls from staff in outpatient clinics when home health questions, insurance issues, and other problems arise.
"They are not being treated as inpatients, so technically they aren’t my responsibility, but I am more familiar with these patients. If the clinic nurse practitioner needs information, I’m a good contact," she says.
As a case manager for pediatric cancer patients, Mary Nugent, RN, is challenged with ensuring that her patients get the care and equipment they need when they are out of the hospital, a job that is made more difficult by the scarcity of some of the medications the children are prescribed and the wide range of payers and benefits.Subscribe Now for Access
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