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By Susan Merrill, RN, BS, CCM
With assistance from Pat Eshleman, RN, CCM
Note: Resourceful case managers make a difference in the quality of health care. Stories like the one that follows illustrate how skilled professionals facilitate client care while lowering costs. All stakeholders benefit when case managers provide knowledge, know-how, and excellence in process control. These leaders have the tools of the trade and know how to use them.
Jody was referred to me after her case was transitioned from non-managed to managed Medicaid. Reports of previous services administered or supplies used had not been received at the time of transition. However, it was known that Jody had mental retardation and developmental disability caused by encephalopathy. Case management began on a late Friday afternoon when Jody’s mother came to our office asking for diapers and bottle nipples for her daughter. I assessed Jody’s needs while interviewing her mother and then developed the case management plan.
The mother reported that Jody experienced normal development until she was six months old. After receiving a DPT shot, the child developed seizures. The effects of a related high fever led to cerebral atrophy, developmental delay, and hyperactivity. At three years, Jody was dependent in all safety and care areas, except that she was able to occasionally finger feed. Jody also had a tonic bite reflex that caused her to chew through bottle nipples, sometimes chewing through as many as six per day. She was not toilet-trained and needed diapers.
Addressing Jody’s physical and safety needs
Following the interview with the mother, I spoke to the child’s physician and to the Medicaid disability manager. I learned that Jody was receiving early intervention services consisting of physical and occupational therapy. I then formulated a plan designed to meet Jody’s physical and safety needs.
Ordering a sufficient supply of bottle nipples was an immediate priority. However, I expressed concern that there was a significant risk that Jody would aspirate when she chewed through the nipples. I asked the physician to order an occupational therapist to evaluate the child and recommend alternative feeding methods. The therapist recommended that Jody be weaned from bottle nipples to a plastic sippy cup. Even through the cups were not covered under the health care plan, I was able to convince the client care committee to pay for them in the interest of decreasing the risk of aspiration.
Safety while sleeping, an insurance denial, and subsequent approval
Safety at home also was addressed in the case management plan. Jody had no sense of danger and was unaware of her own safety needs. Her crib collapsed from constant rocking, and she slept on a mattress on the floor. Because the family lived in an upstairs apartment, there was great concern that this sleeping arrangement was unsafe.
The evaluating therapist recommended a metal hospital crib. Because Jody could climb over the top of the crib, a bubble top was needed to confine her. The total quote for the crib and bubble top was $3,700. The equipment was not covered under the client’s policy, and the claim was denied by the insurance company. I shopped for a metal crib and found one for $117 at a local store. A net cover for the bed was also found. I then helped the parents appeal the insurance company’s denial of the hospital crib and bubble top. The purchase of the alternate equipment was approved.
Transporting Jody safely and meeting those costs
Safe automobile transport of the child was another challenge. Because of her size and disabilities, Jody could not be transported in a standard car seat. I found a specialized car seat designed to accommodate a handicapped child weighing up to 65 pounds. The seat also fit into a specialized stroller that could be used for transport outside of the car. I convinced the insurance company that Jody’s safety was in peril, and the equipment purchase was approved.
Safe sleeping is again an issue
When Jody reached the age of 4 1/2, she became more mobile and destructive. She destroyed the mesh cover of her crib and the mattress. Confining Jody to her bedroom during sleeping hours became impossible. I researched options for safely confining the child while not completely caging her in. A specialty bed priced at $5,500 was located. Purchase of the bed was not covered under the policy, and the insurance company denied the claim.
A safe-sleeping environment is created and the costs approved
I researched less costly alternatives and found the components of a suitable bed. These included a specialized mattress with a heavy-duty cover, and for the top enclosure, a nylon parachute fabric impermeable to chewing. Using this material, a protective tent was made by a local seamstress. With photographs of the proposed bed in hand, I attended a client care committee meeting. The case was made that the child was severely handicapped, and that risks to her well-being would be far more expensive to the insurance company than the cost of a bed. The total cost of the bed components was $1,423.74, and the claim was approved.
Current client status
Jody is now eight years old and continues to live at home with her parents. She is not toilet trained and functions at a 12- to 18-month level. She is nonverbal, extremely hyperactive, and aggressive. Jody has no appreciation for danger, has a high pain tolerance, attempts to put everything in her mouth, and is often at risk. She needs constant attendance while awake due to severe cognitive impairment and high mobility function.
The case plan continues as developed. The parents contact me when they need additional supplies. Jody continues to attend special education classes. Due to aggressiveness toward other children, she needs a one-on-one attendant. The family has respite care available despite attempts of an early intervention to find someone to stay with the child.
Psychosocial family issues and summary
Jody’s mother is on social security disability for ADHD and bipolar disorder. The father is unemployed pending a social security disability claim. An older brother is disabled with schizophrenia. Despite many family difficulties, Jody’s physical and safety needs plus her overall well-being have been improved substantially through case management intervention, planning, and execution.
Susan Merrill and Pat Eshleman are certified case managers. They received the CCM credential from the Commission for Case Manager Certification in Rolling Meadows, IL.